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SAN JOAQUIi'-'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# / SERVICE REQ�$T#. <br /> OWNER/OPERATOR / <br /> Y. /U "r /p� <br /> FACILITY NAME "``ffff ��V// CHECK If BILLING ADDRES <br /> ! C. <br /> SITE ADDRESS Z 7 z 0 <br /> Street Number Direction Street Name/� (J Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE AP LICATION <br /> ( ) 334-�5Z3 007-/20-0 s $ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> &1-1 ,C� , p // CHECK If BILLING ADDRESS <br /> 71�- <br /> BUSINESS NAME � ✓/ Q� PHONE# —� <br /> HOME or MAILING ADDRESSZ Z/ FAx# <br /> a2, e2a <br /> CITY STATE ZIP G 0 <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 <br /> or 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: 11 -0-5 -04 <br /> /� <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APDL/CANT 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: �,2 F-AC F Su -��Q ria F)4c- <br /> COMMENTS: <br /> yds _ aul. <br /> ` SAN co <br /> COUNT+ <br /> ENVIFtONME TMENT <br /> ACCEPTED BY: r tJ�i n EMPLOYEE#: <br /> C/' <br /> 3 DI 1 3 (J <br /> ASSIGNED TO: r� EMPLOYEE#: DATE: <br /> '"C J�3�(o l l 3C <br /> Date Service Completed (if already completed): SERVICE CODE: 3 iS P/E' : <br /> Fee Amount: P /&-&'L7C, Amount Paid 1 Payment Date ( 3 I G <br /> Payment Type � Invoice# Check# l-7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />