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.JAN JOAQUIK a •OUNTY ENVIRONMENTAL tIEALTI-J 'IEPARTMENT <br /> SERVICE REQUEST e <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AES/DE/VT/AL O/ E/V Sa?oo 3 <br /> OWNER/OPERATOR <br /> R R CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEPDRA1 y�Gkv1 `-T L//VD�N <br /> �t� Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION III <br /> ( ) ©f3 �6 - -6 <br /> PHONEY Ezt. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME - E ` G fuG 1 PHONE# "� f/ � EKT• <br /> HOME or MAILING ADDRESS FAX# <br /> 7 ( ) /n —Z� <br /> CITY n L OG K STATE LP <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 applicati n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT d FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> �/I8 r 64 <br /> PROPERTY/BUSINESS OWNER❑ ANGE <br /> OPERATOR/MR ❑ jIaI AUTHORIZED AGENT <br /> If APPLICANT 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 environniental/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: <br /> COMMENTS: /O l9-0 PA <br /> ��27 A�040,rm <br /> RECEIVED <br /> txC774 AUG 18 2004 <br /> ,t S�JOAQUIN TM <br /> ENVIRONMENTAL, <br /> ACCEPTED BY: D L f V I IVT EMPLOYEE#: 3 H 'U c pl6 <br /> ASSIGNED TO: ESG 0-rr77 EMPLOYEE#: �Q cr DATE: of! V tO <br /> Date Service Completed (if already completed): SERVICE CODE: $2 y PIE: a.6 Q <br /> Fee Amount: �G OO Amount Paid 1 62 <br /> Payment Date - D <br /> Payment Type Invoice# Check# �� R celved y: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />