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" 9 SA JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 7S iM SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE RE=QUEST# <br /> s 4o <br /> OWNER/ ERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> I. <br /> SITE ADDRESS -aag-(p kJ e 11(0, <br /> i <br /> Street Number Direction Street Name city Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CA <br /> i��� � Y~�YY7 0 try eetl0um6�r � Street Name Q <br /> CITY STATE Zip <br /> PHONE#1 L EXT. APN# LAND USE APPLICATION# 4C� <br /> 501) WO-Vio? <br /> PHONE#2 _ II EXT. BOS DISTRICT LOCATION CODE <br /> D`j FS S - b - <br /> ; CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR A <br /> 16 CHECK If BILLING ADDRESS❑ � <br /> BUSINESS NAME PHONE# I JAI J\fIL­1 Er* 1 <br /> RECOVFD <br /> HomE or MAILING ADDRESS {N(# ) JUL 2005 <br /> CITY i!' STATE SAN JOAQUIN'i 11mr-01:9A <br /> CouNTv <br /> BILLING ACKNONVLEDGEMENT: I, the undersigned property or business owner, operator or same, �— <br /> acknowledge that all site and/or project specific ENVmoNMENTALHEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me "or my business as identified on this form- <br /> 11 <br /> orm . <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 JOAQUN <br /> COUNTY Ordinance Codes,Standards,STATE and FFDERAL laws. <br /> APPLICANT'S SIGNA I DATE: <br /> .I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AG ❑ OTHE*t =DAGENTIfAPPLICANT is not the BILLINGP,4RTY pro of authorizatiquired 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 JO QUIN 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: j� ( F' LJ (2-0 NS tL <br /> COMMENTS: <br /> �Z' .L11 E_9CT7 u rJ q`– EXT .Ji v F �'FtS7 t �1 � <br /> ACCEPTED Y: ,EMPLOYEE#: DATE: 7 2Cl pS. <br /> ,� <br /> ASSIGNED TO: EMPLOYEE#: n f DATE: _712--00-5 <br /> Date Service Completed (ii already completed): SERVICE CODE: d{n I PIE: 42 O2– <br /> Fee Amount: t �, fi.(l Amount Paid `>I� I-)� Payment Date `"Z ;3D C),5-- <br /> Payment <br /> Payment Type li Invoice# Check# 11 yD Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />