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SAN JOAQU' '�OUNTY ENVIRONMENTAL HEALT 1EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# i SER'ICE REQUEST# <br /> A-'yW,'Jd -52003(a¢43 <br /> OWNER/OPERATOR <br /> l CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> CAL.t r- <br /> SITE ADDRESS r ; C>1; <br /> Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t1moNumber Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USEAPPLICATION# <br /> tzon) lob 1 228- /3a-12- - cam- to <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> —T CHECK If BILLING ADDRESS <br /> ]t�1 <br /> BUSINESS NAME PHONE# EXT' <br /> (-,!v — as <br /> HOME or MAILING ADDRESS r FAX# <br /> CITY STA-rt. i zip s � <br /> BILLING A KNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIt DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <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,Stanch-ds ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN ERIA OTHER AU' ORIZEO AGENT <br /> IfAPPLLCANTis not the BILLING PARTYp of of authorization to si is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: NVhen 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: J./(-f7¢.¢�/� L off!Or.J G- ST�.cd <br /> COMMENTS: / 1P316Al/ 3 ✓�3�J <br /> J G� •7..r7DEC 182003 <br /> �yjk9v �D,iylG6��/ r <br /> SAN JOAQUINCOUNTY <br /> i�6!! <br /> ENVIRONMENTAL ENTAL <br /> ` HEALTH DEPARTMENT <br /> i !j{FiUJ'� <br /> ACCEPTED BY: O L r v rr .p A PLOYEE DATE: 12 It e/03 <br /> ASSIGNED TO: GO J0 I 0-11,4 EMPLOYEE#: ?3-7q DATE: <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: $2S- PIE: 2b•oL <br /> Fee Amount: c�(qs p� Amount Paid Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />