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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 <br /> OWNER/OPERATOR <br /> Q 1245 T7 t_I—f^r--O Il�-I v CHECK If BILLING ADDRESS <br /> FACILITY NAME rJ <br /> SITE ADDRESS 7t}3�{. n( Pc,P�sra LA�1d6 L/tVO151Q F�� <br /> 23 <br /> Street Number Direction Street Name Ci ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2000 ( Ft—Cor> F AD <br /> Street Number Street Name <br /> CITY L—t N D E/J STATE CJA ZIP c l S 2.310 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (AM ) 60-1 Oji I— 35c, —0+ PA— 05— Z9 3 Cms) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT' <br /> b l L�-o r1 M v►Zt'EFY 20 334-(-(-13 <br /> HOME or MAILING ADDRESS FAX# <br /> So (26 ) 334-0-773 <br /> STATE C ZIP `75 <br /> 74 <br /> _' <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 HEALTIi DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU��O` ERATOR <br /> /NIANDATE: / APROPERTY/BUSINESS OWNER A - OTHER AUTHORIZED AGENT L7 <br /> If APPLICANT 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: c A +t <br /> COMMENTS: -o RECE ED <br /> MAY 1 6 2005 <br /> SAN JOAQUIN CO ANN <br /> ENVIRON f <br /> ACCEPTED B EMPLOYEE#: - DA <br /> ASSIGNED T EMPLOYEE#: DATE: <br /> i <br /> Date Service CotTipleted (if already completed): SERVICE CODE: P I E: ! C-'_ <br /> l <br /> Fee Amount: �, Amount Paid 46 R>(, C-)� Payment Date <br /> Payment Type ✓ Invoice# Check# l� Received By: <br /> El-ID 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />