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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUiY ID# SERVICE REQUEST# <br /> 61P-00+577 <br /> OWNE RAT <br /> CHECK If BILLING ADDRESS <br /> FACluir NAME <br /> SITE ADDRESS :;L L, <br /> Street Number Diraceon StmtNams 'C I Gado/ <br /> HOME Or MAILING ADORES (if Differe from Site Address) <br /> stmet Number Street Name <br /> 4L TATE P <br /> PHONE#1 En. APN# <br /> LAND USE APPLICATION.# <br /> ?,+-as- lM.$) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ez' <br /> HOME or MAILING ADDRESS , FAx# <br /> 1 1 <br /> CITY 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this applicatiod that the work to be performed will be done in accordance with all SAN JOAQUIN - <br /> COUNTY Ordinance Codes,Standards, d F E am6 <br /> CC,_�..,.� <br /> APPLICANT'S SGNATU <br /> IRE: DAtE:� �r Z4 �®Qar� <br /> PROPERTY/BUSINESS OWNER❑ (0=MAN GER OTHER AUTHORIZED AGENT <br /> JfAPPL/CANT is not the BmL/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 /> 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: �C.0 r2. t= ie r- <br /> -,4,-CF <br /> COMMENTS: (L- Z -QS <br /> �c�u'tTlle+/i�,�j �D R�C�IVEO <br /> Wil. F �st�ylo 2005 <br /> pU1N CaUNN <br /> ACCEPTED BY: C)L I U&,kZA EMPLOYEE#: V 3 2-4DATE: �5N t ryIEIdT <br /> ASSIGNED TO: EMPLOYEE#: TIG( <br /> JP as, <br /> C.C' c J~ C t{LfDATE: 3 TIG CLS <br /> Date Service Completed (K already completed): SERVICE CODE: I S' PIE: <br /> Fee Amount: ( ?-&-00 Amount Paid $'�.D-D Payment Date _ <br /> 3 (L a5 <br /> Payment Type Involce# Check# PfLfS Received By: <br /> EHD 48-02-025 SR FOfSM Golden Rod <br /> REVISED 11/172003 .( ) <br />