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NAN JUAQU1N UOUNTY ENVIRONMENTAL t1EALTH VEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �3 4211 <br /> OWNER/OPERATOR <br /> C-A R / O CHECK if BILLING ADORESS� <br /> FACILITY NAME C' <br /> e—, Ariz !—SoW p T <br /> SITE ADDRESS JG TD7�1 t�07�l7 p �' PbN C . <br /> O Street Number Direction Street Name I� Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from ite A��dd��rlIess) <br /> G V� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Er. APN# LAND USE APPLICATIO # <br /> ( ) q'J- I�D�-{J I 17 <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> Y 2 Z CO v1— CHECK if BILLING ADDRE55� <br /> BUSINESS NAME r7/�` PHONE# E". <br /> HOME or MAILING ADDRESS ! I n �t FAX# <br /> OL ( ) <br /> CITY A <br /> 0 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 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 TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t� DATE: <br /> ' t <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT(!D <br /> � TITf�q (f LJa T— <br /> I,fAPPLiCAAT is not the BILLING PARTY proof of authorization to sign is requir A 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 enviromnental/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 REQ//UEES,tTED: 5JL(� 9/(UE9 RECEIVED <br /> COMMENTS: I S (.C� + �` t TQC V/e L✓ ��/�y //tel ; / O 2004 <br /> •' �� 64^"�c;sJ F�J,�/P�/�+1�' � AUG 1 <br /> p b_ <br /> SANNVVIIRONICOUNTY <br /> 1 HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L. _ EMPLOYEE#: ' �?I'Ia DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P/E: a 3 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />