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SAN JOAQLIIN..f,,-,,OUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ip# SERVICE REQUEST# <br /> L tf <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FAciurY NAME <br /> rel G.[[L��.-L" <br /> SITE ADDRESS Oct I'�}4 "��/V f�• rRAG' q�304 <br /> Street Number Dlrec on Set Na Ci zip code <br /> HOME or MAILING ADDRESS (if Different.from site Address) ��d� ��/�7`p� RA AIC 9 ROA fl <br /> Street Number S r e Name <br /> CITY r — � / STATE eA ZIP � <br /> AI C Ql� <br /> PI40NE#1 EXT. APN t# LAND UsE APPLICATION# <br /> PHONE 102 EIT• BPS DISTRICT LOCATION.CODE <br /> 0 G�4 <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> 049AJ Cl <br /> PHONE <br /> # lel/ - d EXT. <br /> BuslNEss NAME r <br /> HOME or MAILING ADDRESSi•� FAIc# <br /> d a j1 - <br /> CITY STATE ZIP <br /> Mb— <br /> BILLING ACKNOWLEDG)EMEN : 1, the undersigned property or business owner, aper f same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated w' this project or <br /> activity will be billed to me or my business as identified on this form. JUN C - �� <br /> 1 also certify that l have prepared this application and that the work to be performed will be doneE#A4 f "fiMOAQUIN <br /> COUNTY Ordinance Colles,Standards,S and FED laws. PERMIT/SERVICES <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BCISWESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIzED AGENT#.,t <br /> If APPLICANT is not the BILLING PmTY,proof Of u tltorrzatia#t to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 1OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or any representative. i <br /> TYPE OF SERVICE R#QuESTED: <br /> COMMENTS. In <br /> fiA�'ti' <br /> ACCEPTED BY. 4)C t,/,(C t EmpLoYEe#: �✓ DATE: 4. <br /> ASSIGNED TET: EMPLOYEE DATE: & 10 <br /> CIC <br /> Date Service Completed (if already completed)' SERVICE CODE: 52.Z.-. PIE: -Z&O � <br /> Fee Amount: ."�-�f7 -&'A) Amount Paid �Chel <br /> Payment Date O <br /> Payment Type ,�" Invoice# Received By: +� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />