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SAN JOAQUIN C NTY ENVIP MENTAL HEALTH D �,RTMENT <br /> SERV <br /> ICE <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oo37 -3l <br /> OWNER/OPERATO CHECK if BILLING ADDRESS <br /> FACAM NAME <br /> SITE ADDRESS // /N �,y� 97J <br /> Se Sbeet'llumber Dtrection Street Name C Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CrrY S7 E ZIPS <br /> APfJ$ LANDUSE APPLICATION# '•��/ <br /> for <br /> PHONE#Y IJ Exr. BOS DISTRICT LOCATION CODE <br /> G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LCHECK if BILLING ADDRESS yy <br /> d� -t- <br /> BUSINESS NAME PHONE l- <br /> HOME Or MAILING ADDRESS Ax# <br /> CIrySTATE fY/) Zip <br /> / <br /> BILLING ACIINOWLE GEMENT: 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 applicat' a be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT d aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA /MANAGER OTHER AUTHORIZED AGENT❑�Jy/ ' <br /> If APPLICANT is not the BILLING pro of authorization to sign is required Tirfe <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: �tt�r r,G� S(.L r�S L< r1�E <br /> COMMENTS: 5 y RECEIVED <br /> MAR 4 <br /> 2004 <br /> SANJOAQUIN <br /> ENVIRONMENTAL <br /> EM <br /> OUNTY <br /> ACCEPTED BY: O ct v'er so-4 EMPLOYEE#: 2_� I DATE: 312—Wr)LI <br /> ASSIGNED TO: T,12.1N 0 A-a E EMPLOYEE#: 00( b DATE: 3 Z 0 <br /> Date Service Completed (if already completed): SERVICE CODE: 31 P 1E: <br /> r <br /> Amount: � Amount Paid - �i'( Q�� Payment Date '3 .aUment Type-�, Invoice# Check# 1� Received By. <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />