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SAN JOAQUIN )LINTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ES/ P EIV EIA L "A-4-,9W d 0 3 (10 (0 2 <br /> OWNER/OPERATOR <br /> CHECK IL BILLING ADDRESS <br /> M S- f t eE G/ND L OHLE�VDo�eF <br /> FACILITY NAME <br /> SITE ADDRESS w LJN�E flof}D Ti?ACI 9 304 <br /> 70/ Street Number Direction Street Name chi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) s puT/-/ LA/19 ME IZ,5 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> T c Cq 95 3 o 4 <br /> PHONE#11 Ex . APN# LAND USE APPLICATION# <br /> ( ) 913s- - 4000 248 -080 -49,r Z9,30 3/ z P- 9/-/4 e -7-R -0/0 -/o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> D C �,ICHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Eu. <br /> SNE �ONSGC�-T ( 6 -/ 03 <br /> HOME or MAILING ADDRESS FAX# <br /> P Box <br /> CITY LOcic, <br /> STATE C it ZIP q,5-,.l <br /> )�,e/ <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��iork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT a d FERE. Cla Is. <br /> APPLICANT'S SIGNATURE: DATE: —� — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHE UTHORIZED AGENT <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: FA 5U RFAGE COMA f W/A-64 Tl OCL O E✓/E VV <br /> COMMENTS: ME <br /> N I <br /> N JOAQUIMEC1TAl <br /> ACCEPTED BY: D(_! �� I�_�- EMPLOYEE#: fj <br /> ASSIGNED TO: Lt� EMPLOYEE#: / µs-& DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /S PIE: <br /> Fee Amount: (I D G Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />