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SAN JOAQU: OUNTY ENVIRONMENTAL HEAL7'-�7EPARTMENT <br /> SERVICE REQtJEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS ElFACILITY NAME (� t <br /> SITE ADDRESS ur7 I •2— 1 }S X-27 <br /> )C3& ! Street Number Direction Street Name eit' Zin Code <br /> "i AILING ADDRESS (If Different from Site Address) <br /> S-P 6 Street Number Street Name <br /> TA IP <br /> PHONE#1 i Err. APN# LAND USE APPLICATION# <br /> c91 7-�5;-?- 3 - 05-3A 2 �� <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> c�c9 1 3 77 b 3 � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ k4 <br /> BUSINESS NAME PHONE# Exr• <br /> HOME or MAILING ADDRESS FAX# <br /> { 1 <br /> CrIY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form fi <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , TA and FEDERAL laws. <br /> APPLICANT'S SIGNA DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MA> GER &T OTHER AUTHOPAZED AGENT❑r w, VA.e fz-- <br /> if APPLicANT is not the BimmG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ill l 1 ,J Cv— 0-�L S-u.'-'"1 A-Q t Z_ 1 <br /> COMMENTS: �J��C�S R C'E I VE D <br /> JUN 3 2005 `►: . . (.,1t�c.�—; <br /> • � .,vz A�QUIN U�T�.� r �µ- -- <br /> ACCEPTED BY: UEMPLOYEE#: ©3 DATE: <br /> r <br /> ASSIGNED TO: E,6 t EMPLOYEE#: 5-3(,( DATE: (P 3( - <br /> Date Service Completed (if already completed): SERVICE CODE: j;t S 9y�� P1 E: Z(,,p 2 I <br /> Fee Amount: E{ g )_�� �7.� Amount Paid Payment Date O <br /> Payment Type Invoice# Check# Reiceived By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> RE=VISED 11/17/2003 <br />