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SAN,JOAQUIN—,—OUNTY ENVIRONMENTAL IIEALTPARTMENT � � � --76 7 ') <br /> SERVICE REQUEST / <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 3 0 J'f 5 11" �J (� {� AZ <br /> .Street Number DirectionnNme T/ Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t Et APN# y 0�V LAND USE APPLICATION# <br /> PHONE#T ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CON RACTOR / SERVICE REQUESTOR <br /> REQUESTOR i _ _ <br /> DDRF S <br /> BUSINESS NAME I r PHOt <br /> HOME or MAILINGADDRE S Fax <br /> CITY STATE/ ZIP <, ` ^ - l� <br /> w v <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTA IIEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as ideied on this <br /> ntifnri. <br /> I also certify that I have prepared this application C ork ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S nd FS. <br /> APPLICANT'S SIGNATURRE: ,X DATE: <br /> PROPERTY/BUSINESS OWNERVI OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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: IPAYMENT" <br /> COMMENTS: ' / _ C SSlR,M RECEIVED <br /> { JUN 1 ,�� 2004 <br /> JUN 10 2004 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY HEALTH DEPARTM NT <br /> ACCEPTED BY: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): Z ZI SERVICE CODE: P 1 E: <br /> Fee AmOVnt: C Amount Paid ! Payment Date �0 p <br /> Payment Type V J Invoice# Check# —� Received By: <br /> EtiD 48-02-025 SR FORM(Golden Rod) <br />