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JAN'JOAQUIN-"OUNTY ENVIRONMENTAL-14EALTI-T'RIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /'�e5IOEN7-IA4- <br /> OWNER/OPERATOR ,/ <br /> /Yk . EN2 VA /V V t/CR�E/il CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS5-j_0, ,/ L1 ,Ve N u E STd C KT0� ��Z <br /> Street Number Direction ✓ V VStreett Name C• 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 PLICATION# <br /> 933- 9Zr/ /g3 -/oa--v3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � CHECK if BILLING ADDRESS oN C�/�5n/� <br /> BUSINESS NAME PHONE# EXT* <br /> 3 <br /> NOME Or MAILING ADDRESS D / FAX# <br /> ( ) �v6 g—Z5­98 <br /> CITY STATE ^ zip 9 g <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 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 1 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, TE and F L laws. 9 <br /> APPLICANT'S SIGNATURE: DATE: / r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AIANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not th e BiLLiNG PA R TY,proof of dult1l,orizadoit to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: S 2 f7A C C /�� .1 to u 2FAGE C61^17–,41W IAIA TJ ON kr�027_ 10—_-V/C CAI <br /> COMMENTS: le;,XZ1g/G 3/ PAYMENT <br /> , 027�2L�crl� RECEIVED <br /> ��r" stern Ya- SEP 17 2004 <br /> SAN JOAQUIN <br /> C01 jNU <br /> ACCEPTED BY: L 1 V �t EMPLOYEE C 3L� HEAL ME <br /> AR D <br /> ASSIGNED TO: C C G7 EMPLOYEE#: 5"o Gr DATE: 9 f-710 <br /> Date Service Completed (if already completed): SERVICE CODE: 3 is P/'E: <br /> . 1 _�2_6G 3 <br /> Fee Amount: [& Amount Paid 1 — Payment Date f 7�_i2 <br /> ! <br /> Payment Type Invoice# Check# eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />