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SANJOAQUIN COUNTY El\::7IRONMENTAL HEAI TH DEPARTMENT <br /> �- SERVTCE,REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S (� On33 � 1� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS G17�1t FFEn/iQY tQoAO F,44�4t/N47n.J 95230 <br /> Street Number Dlreetton Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E)(T• APN# LAND USE APPLICATION# <br /> (2c9 ) $3(0 -51J2o 20-7- 07o •-v 8 <br /> PHONE#2 T BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> MI L C '•T'7-l✓ CHECK If BILLING ADDRESS <br /> BUSINESS NAME Di mLOri t ( ��Y ?1o9 3'3.+ 66-(�PHONE# t3 ' <br /> N tr^A, <br /> HOME Or MAILING ADDRESS FAX# <br /> P. 0 0 ) 334 -077-3 <br /> CIN t STATE e� ZIP c( S 2-4-1 <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 erfarmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TE and FEDERAL laws. r <br /> APPLICANT'S SIGN A DATE: `5_ 7-03 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the B/LL/NG 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 /> inforination 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. SEN i <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ,;NO3 - lZ 1 Y�l �/P��e��r f{j�{/�pAr'p�W S SAHNI�OPOUtN S pNGE H <br /> I`O 0 POBLIC HE PITH �tTH g1N510 <br /> /0/1710 3 - rIZ k-v'' <br /> APPROVED BY: 2-L 'L EMPLOYEEM Z "L DATE: <br /> ASSIGNED TO: rn yJdF EMPLOYEE#: 4-+— DATE: S v &J <br /> Date Service Completed (if already completed): SERVICE CODE: 315'- 1 PIE: <br /> Fee Amount: •-) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />