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SAN JOAQUI41 OUNTY ENVIIZONi,:ENTAL HEALI� DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E � �/� <br /> OWNER/OPE Tqll <br /> i C'--1I /• CHECK If BILLING 5 <br /> ll l ( 7 <br /> FAcLnY NAME 1 _ <br /> SUE A^7DDD)RESS �C11-YY\PGS <br /> C�L•- . Stre<t Numlxr Direction Street Name e" t Code <br /> HOME or MAILING ADDRESS (If Different from Site Addres <br /> if <br /> '1re\ A Street Number Street Name ��\\ <br /> CITYzip <br /> _T N ZZV <br /> C(:1- <br /> PHONE#1 ExT• APN# LAND PLICATION# <br /> (7o�1 �S1 -3233 oo oy' a.511 �`✓ <br /> PxoNE#2 Ext. BOS DISTRICT LOCATION' , <br /> (ZD41 31p5'— ��J p <br /> CONTRACTOR/ SERVICE REQUESTOR =_ <br /> REQUESTOR S <br /> CHECK If BILLING ADDlFE58'I-1 <br /> BUSINESS NAME PHONE# " <br /> HOME of MAILING ADDRESS FAY# , <br /> CITY STATE LP <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 ass.Qciated with this project or <br /> activity will be billed to me or my business as identified on this form J <br /> I also certify that I have prepared this application and that the work to be perfo d will be doue`llra'6 6i dance with all SAN JOAQUIJ <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL lav <br /> APPLICANT'S SIGNATURI . DATE: r/) <br /> -c— <br /> PROPERTY/BUSWESSOWNER OPERATOR/ ❑ ERAuTHoRlzEi)ACENr❑ <br /> IjAPPLIG1NTis not the JIlLLtNGPAR7Y.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 environmentallsite assessmeat" <br /> information to the SAN IOAQIIIN COtR7jY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time rt Is <br /> as <br /> provided to me or ' ......representative. . ', <br /> TYPE OF SERVICE REQUESTED: - ;3.LL&e!F-A iF— 6,S:,LC i2._F4c i-=:—:Cpm- _ D A97 ' <br /> CONNEHTS: <br /> JUN 1 7 2004 <br /> ENVIRONMENT HEALTH <br /> ACCEPTED BY: OL L EMPLOYEE#: 3?,� DATE: (7( O <br /> ASSIGNED TO:. ..M� th/:4 EMPLOYEE#: ,,.53�� DATE: _ &11-7 O,�" <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amopnt: g O Amount Paid I O�_ Payment Date <br /> Payrn¢ntType - Invoice# Check# "I - a' - ReceivedBy. <br /> EHD 48-02-025 SR FORM(Golden <br />