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USAN JOAQUD WNTY ENVIRONMENTAL REALTI 'EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT R <br /> CHECK If BILLING ADDRESS v <br /> FACILITY NAME / <br /> L <br /> SITE Aj}�yp�p�ES—Sf` / <br /> `� V Street Number Direction "It <br /> 5 <br /> ed <br /> HO r NAILING ADDRESS (If Different from Site Address) <br /> (� Street Number Street Name <br /> CITY io TATE ZIP <br /> PHONES##1. EKT' APN# LAN US PLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCAnoDE <br /> O <br /> ( , <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� ' CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( r (r PHONE# -7 <br /> , �7 zz <br /> HOME Of 'ILIf{G ADDR 7 v7, 3 j 51 cz 2 <br /> IS <br /> CITY O STATE ZIP 17 <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 th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STA an FEDflR L Ws. <br /> APPLICANT'S SIGNATURE: r DATE: — 0 r <br /> PROPERTY/BUSINESS OWNER❑ O <br /> RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT11~� 6r— <br /> I,fAPPLICANT is not the ILLING PARTY proof of authorization 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 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: SOL-L 'Lc C B f L. IT STZt GJ .�iFir'J S&/ / ( C. <br /> COMMENTS: R CEIVED ,3Y C7�" �Sf <br /> UNTY <br /> SAN NV RONMENOA UIN OTAL <br /> ACCEPTED BY: �' L L�Gt EMPLOYEE#: � 32 DATE: 3 �6 <br /> ASSIGNED TO: >�Q/A/4 EMPLOYEE#: J fo DATE: 7 3 OY <br /> Date Service Completed (if already completed): SERVICE CODE: -C'Z'Z P 1 E: -2-(a <br /> Fee Amount: Ot 6-0 Amount Paid � ��� C-�� Payment Date <br /> Payment Type Invoice# Check# 3 -S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />