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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ;OWNE <br /> Business or Prope FACILITY ID# SERVICE REQUEST# <br /> f�q(/OPERA/TOR <br /> 4: L7_� CHECK N BILLING ADDRESSE] <br /> FACILITY NAME �T <br /> SITE ADDRESS CJ' O� G n,✓ <br /> 11SS Street Number DimGction <br /> Street Name ` C v <br /> HOME Or MAILING ADDRESS (If Different from Site Address) t'33 !— �C �v Zi code,p <br /> CITY Stmet Numbar Street Name <br /> STALacfr CTE/ zip ! S2 Z <br /> PHONE O1 EaT APN# LAND USE APPLICATION Z <br /> PHONE 92 Err. <br /> BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 4rne-S ]� dC `�� CHECK If BILLING ADDRESSO <br /> BUSINESS NAME PHONE# Ex <br /> HOME Or MAILING ADDRESS <br /> 53S Salor p \ Fax# <br /> CITYt i lcc Ti c 1—� . 1 1 �3/ — 2 ,3 7 `3 <br /> STATE C4 ZIP 9iS <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 /> I also certify that I have prepared this application and that the work tWPC performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE. z 3 �o <br /> PROP¢RTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTRERAUTRORIZEDAGENT® C /yIp <br /> IjAPPLICANT is not the BILLING PAR ry Proof of authorization to sign is required Titre <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: /1 @✓/e(,(j Sv r <br /> Cc <br /> 50 lDur <br /> S <br /> COMMENTS: n <br /> RECEIVED ) <br /> Dtl— <br /> AUG 2 3 2005 <br /> SAN JOAQUIN COUNTY <br /> IRONMENTAL <br /> ACCEPTED BY: _ EMPLOYEE#: S <br /> ATE: LS <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> Date Service Completed IN already Completed): SERVICE CODE: <br /> 71 <br /> c PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />