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SAN JOAQUIT- �OUNTY ENVIRONMENTAL HEALTT' A ZPARTMENT <br /> SERVICE REQUEST <br /> Type oL usiness or Property FACILITY ID# SERVICE REQUEST# <br /> 52 add i 3� <br /> OWNER I OPERATOR <br /> V L f D� ��� IIAI� CHECK ifBILLING ADDRESS <br /> FACILITY NAME <br /> g, r <br /> SITE ADDRESS J +y/ t'�Z <br /> Street Number Direction / Street Name Cit Zi Code <br /> HOME or (LING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY Al (r ^ STATE 5--_?4�7 <br /> PHONE#1 �t EXT. APN# /Vl LAND 11$ LICATION# <br /> 7 Z 2 rr Ls-V o 0- '7/ <br /> PHONE#2 EXT. �y Ir <br /> S DISTRICT LOCATION GODS <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE4UESTOR <br /> f @ CHECK If BILLING ADDRESS <br /> BUSINESS NAME / � PHONE# EXT. <br /> 17O � C / 9 ��� 6P'7 7 z <br /> HOME OC MAILING ADDRESS <br /> G Ss-- 2 Lf, <br /> CITY PC) �Q 70 � � /� STATE �;)r��SZIP <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 i WE, ,RrA(L <br /> I also certify that I have prepared this app ation anrmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards 'ATE and FE <br /> APPLICANT'S SIGNATURE: DAVE: 2 - 2- <br /> OP <br /> PROPERTY I BUSINESS OWNER❑ OP ATOR I ATHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARK, r of 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 T /T-"',l C_c.q 4, Cs 7} 0 (-7C%U <br /> COMMENTS: RECEIVED <br /> SAN JOAQU)N COUNI'f <br /> ENVIRONMENTAL { <br /> ACCEPTED BY: OL-[ L/�I r� EMPLOYEE#: �� Z DATE: <br /> ASSIGNED TO: lq i. I r�1 EMPLOYEE#: 5~j DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S r, P E: -2 D <br /> Fee Amount: Lk[os �, Amount Paid Payment Datel �c�� <br /> Payment Type Invoice# eck# Received By: <br /> Ch �! <br /> EHD 48-02-025 ` 1 �n���� n /y SR FORM(Golden Ftod) <br /> REVISED 11/17/2003 7�'+"Cs ✓,[ <br />