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., I' OUAYUttyVOUNTYENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> EFAclury <br /> f Business or Property FACILITY ID# SERVICE <br /> REE/QUEST# <br /> OWNER/OPERATOR <br /> �Y �J <br /> Ai [� <br /> I h-� LI K CHECK If BILLING ADD ESS CI <br /> NAME <br /> SITE ADDRESS <br /> Street Number Direction Q Street Nae <br /> HOME <br /> 3!_ <br /> HOME or MAILING ADDRESS (If Different from Site Address) cl zt code <br /> I Street Number Street CITY1IName <br /> CXC_ STATE C .tet ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c K > C> ! Z 11 z 0-3 Su) <br /> PHONE#2 EXT. BOS DISTRICT <br /> ( ) LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ---r— I <br /> , C �I.0 ZLJI/ IZ'1� £ L)C2 to WC-4�.+-✓/(• CHECK If BILLING ADDRESS® <br /> BUSINESS NAME y 1 / PHONE if ExT. <br /> ✓I I- , VOCE l Z`�- `2300 <br /> FIOME-or MAILING ADDRESS FAX# <br /> / /-74— riZ C� �;z4 ( ) ez — 03 <br /> CITY mc, vt f+- C Li STATE C (4, ZIP (� -3 2 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: L �J Gam` DATE: I ' I Q c 9 2 oc)6 <br /> PROPERTY/BUSINESS OWNER❑ OPERA O /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLIN ARTY proof of authorization 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: _i <br /> COMMENTS: 7�B �e.✓�'�'t^//taJ G/yye...t U <br /> PA'JIa�a.F - MA v 1 Zp <br /> M,> �p06 <br /> r.r^/ SAN JOApUIN COU <br /> T3{(Ob �� 1 �,.r- `� ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> �[ - SIN <br /> ACCEPTED BY: / EMPLOYEE#: p1v` <br /> ASSIGNED TO: EMPLOYEE#: 1`� ATE: L <br /> Date Service Completed (if already completed): SERVICE CODE: 7;71-S PIE: <br /> Fee Amount• / Amount Paid 1 ✓�' Payment Date / <br /> Payment Type G Invoice# Check# 2"2 g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />