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SAN JOAQUII-f- OUNTY ENVIRONMENTAL HEALTVs DEPARTMENT <br /> I � ; <br /> M SERVTCE`REQUEST .. <br /> ,i Type of Business or property FACILITY!D# SERVICE REQUEST# <br /> TffF �ftl L S 2/f Tf MD,=Tf��fISC <br /> S P-co -� 3 <br /> OWNER 1 OPERATOR.- <br /> ��D�L 4'/W v 2 � c A,1f s?r M�,-41,l/ :p, / CHECK if BILLING ADDRESS <br /> FACILITY NAME - <br /> SITE ADDRESS <br /> 3770 w C�rQ,�,� Li�'✓f <,-/ <br /> Street Number Direction Street Name a -' Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) - <br /> ! Street Number fk Street!lame CITY <br /> STATE <br /> i PHONE#1E T APN# LAND USE AaPLICAN# <br /> I PHONE#2 Ex-r. <br /> (Ze f 3 2, _ / / WSDESTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUEST'OR <br /> II REQUESTOR - <br /> k 5�//F s 'If 96,11L _ CHECK if BILLING ADDRESS❑ <br /> 11 BuswEss NAME PHOIue# EXT. <br /> HOME or MAILING ADDRESS Fax# <br /> t <br /> CETY - - <br /> I 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: <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 /> I COUNTY Ordinance Codes,Standards STATE and FEDERAL laws. <br /> I APPLICANT'S SIGNATURE: DarE:. d <br /> a <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT❑ <br /> ` If4PPLICANT is not the BILLING,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. ENT <br /> PAYM <br /> TYPE OF SERVICE REQUESTED: U RECEIVED <br /> COMMENTS: . <br /> JUL 8 2004 <br /> i ,ti •_ � �.: <br /> ACCEPTED BY. s� <br /> ae <br /> ASSIGNED TO: <br /> DATE: y - y <br /> Date Service ompleted (if already completed): �. y SER ICE CODE: PIE: <br /> Fee Amount: Amount Paid "'ICTOPayment Date 7 fl() <br /> Payment Type LZInvoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> . f <br />