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r <br /> SAN JOAQU' OUNTY ENVIRONMENTAL HEALTF ?PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ,9 /A 4 /� //`� CHECK If BILLING ADDRESS <br /> FACILITY NAME (�/� C�..D�OCs�/C�—� <br /> SITE ADDRESS <br /> 7 Street Number Direction (A� AStrleett Name Ci-t-Y Zip Code <br /> HO E or MAILING ADDRESS (if Different from Site Address) �t/G 1 <br /> Street Number�KT'RNAN StreetVNaF 1 <br /> CITY Mo D O STATE (:'-:A ZIP CT6315 r4S <br /> PHONE#'I � �� E"T• APN# LAND USE APPLICATION# <br /> ('2M64 <br /> �Z 1Qf14--6,40—a ;0c1 <br /> PHONE#2 EXT. BOS DISTRICTT7CATION CODE <br /> ff <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` ,I� lop qP—W � tf� <br /> V <br /> (�(/ CHECK if BILLING ADDRESS <br /> BUSINESS NAMEA J� � {'1� * ( An PHONE 4�2, ;9 3 () l/ <br /> II41 (316 <br /> O�E r3AILINGD DR 1 If (s,o )4 _4 74 It <br /> CITY STATE ZIP <br /> J <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 <br /> or 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�E and FEDERA <br /> APPLICANT'S SIGNATURI;�':c'/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> ifAPPLICANT is not the BILLING PARTY,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: l` i <br /> COMMENTS: <br /> V G <br /> h �p�gQUihl ,?00/..> <br /> E94P,q a'q4 <br /> M <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 2 Amount Paid �19� Uz� Payment Date 2t p <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />