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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTP DEPARTMENT <br /> *�- SErvICE REQUEST �- <br /> Type of Business or Property FACILITY ID# J; SERVICE REQUEST# <br /> OWNER/OPERATOR ,t <br /> EGL lit A#CM& AM CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS /G 3 Z 2- �. /J`k. NNE A'a �dfl 952¢b <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /�,5/2 AJ, ��G��d�✓e /J� <br /> S Street Name <br /> CITY /D�I 5 ANE ZIP llerg <br /> PHONE#1 L Ext. APN# LAND USEAP CATION v <br /> (�Oq ) 1 2,55 <br /> PHONE#2 Ext. BUS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> I ILE ��Y <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EUT. <br /> U/LPN Zo9 33 - �o%� " <br /> HOME or MAILING ADDRESS FAx# <br /> o . So 2/ o (16I) 39¢ - 0 <br /> CITY 6p q/ STATE �/n ZIP v���/�s <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 foam. <br /> I also certify that I have prepared this application and that the work to be rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: /y— Z.7- / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAP AGER ❑ OTHER AUTHORIZED AGENT <br /> IJfAPPLICANT is not the BILLING PARI o f authorization to sign is require 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 environmentaVsite 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: :5 U ee-i`AGE SIJS 5vde�r-w G <br /> COMMENTS: .x,D,f RECEIVCp <br /> `_�tA'' OCT 2 7 2004 <br /> JOAQU3 n SANN VIRON COUN D, <br /> YJr�,_w9lIQ� HEALTH DE AFNT ENT <br /> APPROVED BY: EMPLOYEEM DATE: (p 0 <br /> ASSIGNED TO: EMPLOYEE#: !T DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: S P I E: �0-3 <br /> Fee Amount: Amount Paid — Payment Date / I? pQ v iq V <br /> Payment Type „ Invoice# Check# Received By: /, -C <br /> EHD 48-01-025 SERVICE REQUEST FORM/ <br /> REVISED 6-5-02 <br />