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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 461zlcac7 <br /> j52ob�/�� I <br /> OWNER/OPERATOR <br /> /YI/. , 04RW1A/ IIVM 4 Al, CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ZSmer 5 .51'm! M5 u L �S CA 4-0^/ Z-0 <br /> rection Street Name <br /> city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#f EXT. APN# <br /> LAND USE APPLICATIO <br /> PHONE#2 EXT. BOE DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> NF CHECK If BILLING ADDRESS <br /> BUSINESS NAMEn����� n��� �� w // --fPHONE# EXT. <br /> HOME Or MAILING ADDRESS F, 0 . <br /> � ��� F,4X# <br /> O . ( ► ?e <br /> CITY -r g Z-a G(.,-- STATE CA <br /> 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 <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 applicatip and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT a FEDERA <br /> APPLICANT'S SIGNATURE: DATE: oy — �— Q� <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER UTHORIZED AGENT <br /> !f APPLICANT is not the BILLING PARTY,proof of authorizad n 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 GIL <br /> CoN Ar+�in/ATjo� . PORT <br /> COMMENTS: <br /> y/DY0 PAYMENT <br /> Xp,�;pt,,i RECEIVE <br /> MAR 7 20 5 <br /> SAN JOAOUIN COU TY <br /> ACCEPTED BY: L/L-1 V' (� EMPLOYEE#: v 3 Z DATE: EpARTM NT <br /> ASSIGNED TO: EMPLOYEE#: 61 if 9 DATE: 3 /7fO- <br /> Date Service Completed (if already Completed): SERVICE CODE: 3 /� P/E: 3 <br /> �(, .C- <br /> Fee Amount: G,.OLS Amount Paid 4 �� D Payment Date .3/-7(v <br /> s <br /> Payment Type Invoice# Check# <br /> � Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />