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SAN JOAQUI"'BOUNTY ENVIRONMENTAL HEALT'DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /OWNE PERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FAaLffy NAME <br /> ITE ADDRESS �S�eetWu�ber Dtrectlan�w �� S�O meN 1 �� I�• Cky ZIP Code <br /> How or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY 1 � STATE ZIP <br /> PHONE 91 ; Ext. APN# LAND USE APPLICATION# <br /> ( 400 — ' P/-- --d 2--2-7 <br /> PRONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE t OR /''LEIAlJ---I X Z ' ��G c�� CHECK If BILLING ADDRESSP) <br /> 'Us SS N1- !k1 PHONE# ExT• <br /> OME or MAILING ADDRESS FAX# <br /> � C ( ) 7 r a <br /> STATE ZIP <br /> RMLEIM 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNA �j <br /> PROPERTY/EASINESS OWNER❑ OrR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Ak <br /> IfAPPmcAhT is not the BrP_ARTr proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE MATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize a release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN CoWry ENVIRONMENTAL 11SALTEI as soon as it is available and at the same time it is <br /> provided to me or my representative. .. <br /> TYPE OF SERVIC RE UESTED: <br /> COMMENTS: <br /> - l <br /> LOP L <br /> NF-AL-,,0;7PARTMF-ffr <br /> ACCEPTED BY: / EMPLOYEE#: 04(o7 DATE: �- <br /> ASSIGNED TO: L. fy� EMPLOYEE#: �,3 G�e DATE: ,0-<r— <br /> Date Service Completed (if already completed): SERVICE CODE:-5�Z-5— P!E CO 0.:2, <br /> Fee Amount: Amount Paid ,� ' <br /> Payment Date <br /> &q vm <br /> Payment Type Invoice# Chock# +�- Received By. <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />