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5AN JOAQUIN COUNTYENVIRONMENTALHEALTHDEPARTMENT d <br /> 0SERVICE REQUEST <br /> 711� . <br /> Type of Business or Property FACILITY IQ# SERVICE REQUEST# C <br /> S'/DENT/Ae IF 5r, Cog5 9a <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> A,e*AuDo alzmy-rgg., <br /> FAciLrrY NAME <br /> SITE ADDRESS 402 ark f d wlaSr /n/C/< �/ACy/ I,�304 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /6 r0$' Spu Tf/ r/ZA e}/ BZ ✓D. <br /> Street Number Street Name <br /> CITY STATE (f.4 Zip �S3 p4 <br /> TI'ZA C <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> RA - S-G29 54e060� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( } <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 0%V C�lr sN� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> vefNE CoNf uZ-r/Nt/ 9-/W0 <br /> HOME or MAILING ADD ESS FAX# <br /> v 7--< 8 <br /> CITY �f, LO1 STATE 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 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 app ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, A E and E L laws. <br /> APPLICANT'S SIGNATURE: DATE:,/ ' 3 ' 04/1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑/10THER AIITIiORIZED AGENT Lk� <br /> If APPLICANT is not the BILLING PARTY,proof ofrization 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 JOAQUfN 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: So -rc//rA(31L /f Y X u4 <br /> COMMENTS: 'VItT <br /> �.I/ RECEIVED <br /> FEB ' 3 2006 <br /> SAP+!JOAQUIN COUNTY <br /> H ENVIRONMENTAL <br /> ACCEPTED BY: I EMPLOYEE#: c DATE: ti <br /> ASSIGNED TO: , — EMPLOYEE#: L DATE: <br /> Date Service Compleled (if a I ready com pi eted): SERVICECOOE: P!E: , Z <br /> Fee Amount: IP2— Amount Paid �d Payme Date 3 D <br /> Payment Type Invoice# Check# t RAciv d By: <br /> EHD 48-02-025 " 5R FOR_M(Golden Rod} <br /> REVISED 11/17/2003 <br /> ,r' <br />