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U�+I. .rvvtjU1N %-0UNTYENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus)T>;;er rProperty FACILITY ID# SERVICE REQUEST# <br /> 11 <br /> OWNER/OPERATOR W / <br /> Z12 e/ "r' CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction <br /> S Direction Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slr¢et Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# <br /> LAND USE APPLICATION# �/�. -L�O��7JJ <br /> ( ) ©cis —.2`f0 -ZZ 23 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr tit <br /> 4 Ll,—"C57/ �q� CHECK If BILLING ADDRESS 19. <br /> BUSINESS NAME PHzr <br /> # E <br /> S <br /> <lfy� YL <br /> HOME or MAILING ADDRESS _ FAx# <br /> let', 0� ) ''3/- 2373 <br /> CITY `-� `,A STATE ZIP �5?� <br /> e3 ! <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 apAcation and that the work to b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE and FEDW2AL laws. - <br /> APPLICANT'S SIGNATURE: c--A+ <br /> — - DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTP� If e-- re— <br /> If <br /> C_ <br /> IfAPP67CANT is not the BILLING 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. .,C, ! T <br /> TYPE OF SERVICE REQUESTED: /Pie-v,y+�j sb; F/L!/, �7�/ RECEIVED <br /> COMMENTS: �`� �V / 5' 3..� " 4,. N0� 2 j 0`5 <br /> �) <br /> SAN ENVIRpEPA MENf <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> J <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Q6 W Amount Paid -- Payment Date <br /> a � <br /> Payment Type ✓ Invoice# Check# Lk2Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />