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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NMW SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESSST,# <br /> OWNER/ OPERATOR <br /> Q/�� / _��� / / /" L� � �a✓e �, ////�,ns CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> [�`jADDRESS <br /> / Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /l 4'rXXt/f'/1 �� /�'�-L Street Number Street Name <br /> CITY STATE ZIP <br /> 1-041i 4f5:19 e 'SZ¢ Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 2vC) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR L' / , CHECK If BILLING ADDRESS <br /> �pl✓ (� �//c'X72 S <br /> BUSINESS NAME / PHONE# EXT. <br /> HOME or MAILING ADDRESS / / \ FAX# <br /> - ( ) <br /> CITY STATE / ,A ZIP 2¢Z <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT and FEDE w . <br /> APPLICANT'S SIGNATURE: 'e."4"4 S/1wzZ—DATE: O/Z�f�yS <br /> PROPERTY/BUSINESS OWNER❑ 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: Z� <br /> COMMENTS: L / �C^ D <br /> l /Zi tC /G GV <br /> 4J <br /> 4 2005 <br /> SAN JOAQUIN COUNTY <br /> MAPNTAL <br /> ACCEPTED BY' EMPLOYEE#: HD <br /> ASSIGNED TO. EMPLOYEE#: 7 DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: <br /> Fee Amount: Amount Paid f Q _ Payment Date g <br /> Payment Type Invoice# V Check# l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />