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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> f SERVICE REQUEST <br />'i Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Y n A n e CHECK If BILLING ADDRESS❑ <br /> lT <br /> FACILITY 144E <br /> SITE ADDRESS 7 5 VAlit" 1t(!. 5 k©CICS P Gly ! JAZ I <br /> Street Number Direction Street Name city Zie Cade <br /> HOME or MAILING ADDRESS (it Different from Site Address) <br /> Street Numger Street Name <br /> CITY. STATE ZIP <br /> -2 -2 <br /> PfIWtE EXT. APN# .4 LAND USE APPLICATION# <br /> .: PHME#2 <br /> EXT. BCS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING AockEss� <br /> Ar~lf. Ind N t:)t- L.1 <br /> it BUSINESS NAME PON # � 6C t- <br /> ExT. <br /> 33 ' <br /> n <br /> HOME or MAILING ADDRESS FAx# <br /> _701 , 33y- o7 3 <br /> 'ClTY. I.0 , <br /> STATE cia zip r 2 t <br /> BILLING ACKNOWLEDGENIENT: I, the undersigned property or business owner, operator or authorized agentaof same, <br /> acknwledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> a identified on this form. <br /> dor activitywill be billed to m <br /> e or to business s <br /> Y <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 FEDERAL la ` <br /> E: <br /> APPLICANT'S SIGNATURE: .:: �/ "' DATE: <br /> PROPERTY IBUSINESSOWNER❑ OPERATORIA'IANAGER ❑ OT HER AUTHORIZED AGENT❑ <br /> ^` !f APPLICANT is not the BILLING PAR proof of authorization to sign is required. Title <br /> `AUTHORIZATION TO RELEASE INFORNIATION 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�t the same time it is <br /> r provided to me or my representative. <br /> TYPE t)fSERVICE REQUESTED, StJ r �AC Substn TrA ce RePor4-- !V T <br /> 5 COMMENTS: <br /> Z006 <br /> °Nf Coo <br /> Hp�pM�T���J . <br /> s FIU7' <br /> ACCEPTED BY' EMPLOYEE#: DATE: D� <br /> ASSIGNED TO: G� EMPLOYEE#: �l7 7 DATE: <br /> Date Service Completed (if already completed): SERIACECODE: P!E: <br /> Fee Amount: j Amount Paid l"1 Payment Date r <br /> Payment Type L� Invoice# Check# 4, Recelived By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 1111712003 <br />