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SAN JOAQUO"COUNTY ENVIRONMENTAL REALT"CIEPARTMENT <br /> SERVICE REQUEST - <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ES 7JENT <br /> SKoeg S93 9� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> • <br /> FACILITY NAME w,F ,qA s nANH <br /> G <br /> SITE ADDRESS 11gF11j1 f 75;- N1 Z-4eg 7DN� APD/ 9sZ¢o <br /> Streel Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY � „T/ STATE i,r ZIP <br /> PHONE#1�1(J rJ �' APN# LAND USE APPLICATION# s� <br /> 0-0f) 42 —/ 4 1 - O - S A <br /> PHONE#2 Ext. BOS DISTRICT O LOCATION CODE — <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> UoN C �s.vCHECK If BILLING ADDRESS <br /> � <br /> BUSINESS NAME PHONE# Em <br /> e- E-'WE GoNSuc7 N i0_146,3 <br /> -1 o Q <br /> HOME or MAILING ADDRESS FAX# ^ <br /> 4 • t3 o sc 37,74 GG 8 -2-5-9 B \V <br /> CITY RLOG�� STATE ZIP <br /> 1715730/ <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S E and FED laws. �— <br /> APPLICANT'S SIGNATURE: DATE: 2—2 3 ey <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of atolloArization 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 a5 Soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: R`A SUI3 SG�lZy.4CE A E'PO <br /> COMMENTS: RECEIV�� <br /> S ENVIROEFP'R N <br /> tJ 1�M Ham,¶-1 DEPAP• <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 12 <br /> ASSIGNED TO: t '�. EMPLOYEE#: DATE: <br /> Date Servic ompleted (if already completed): SERVICE CODE: 3! PIE: Z <br /> Fee Amount: 2, ©D I Amount Paid '�(3 0 Payment Date 2 L 3/10 <br /> Payment Type Invoice# Check# 3 0 q 2 Received By: Mr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />