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SAN JOAQUI-rbUNTY ENVIRONMENTAI�JIEAhT"-DF,. NIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR / <br /> S— <br /> r. \� <br /> FACILRY NAME CHECK if BILLING ADDRESS <br /> 1 TSS �V <br /> SITE ADDRESS 51 <br /> SZD Street umber I Direction Street Name Zi Code <br /> HOM or MAIL/IJ/j'G ADDRESS (if <br /> (If Different from Site Address) <br /> }To. `�x tJ� Street Number Street Name <br /> CITY STATE ZIP <br /> P,�„NE#1) r� APNIf LAND USE APPLICATION# _ <br /> 1 3 - 3 - O -9--m -a8� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I� "v yJ : -A 6ayQ CHECK 1f BILLING ADDRESS <br /> BUSINESS NAMEh� �o3-ZR� � <br /> PHON EXT.vasa <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 work to be PC Dated will be done in accordance with all SAN JOAQuiN <br /> COUNTY Ordinance Codes,Standards,STATE and F laws. <br /> \x, APPLICANT'S SIGNATURE:S--A0 - DATE: <br /> ` PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ER AUTHORIZED AC EN"' -D l <br /> IjAPPLICdNT is not the BILLING PARTY 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 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 /> P <br /> TYPE OF SERVICE REQUESTED: EN <br /> COMMENTS: 3121-*' <br /> .&---Pl +'>- DEC 13 2005 <br /> M.i 6Sec 776 <br /> e Ce'0'dV';J) AIL-- <br /> L SAN N OAQUIN OUfV7y <br /> HEALTH DEPAnTM NTL <br /> ACCEPTED BY: EMPLOYEE#: DATE: ( t 3 S <br /> ASSIGNED TO: S EMPLOYEE#: DATE: 1; <br /> Date Service Completed (if already completed): SERVICE CODE: , S <br /> PIE: <br /> Fee Amount: ' Amount Paid $ Payment Doate �3 6 S <br /> Payment Type �� Invoice# Check# (,1 $ Received By: 1;'- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />