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SAN JOAQUIN 'IUNTY ENVIRONMENTAL HEALTV 'EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> rl c <br /> FACILITY NAME " V Q \ <br /> SITE ADDRESS Li� O �� ����TQ �— �C � '5tOLk}-on S`3t <br /> ,Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> r-a t, z v y 61 - 633 <br /> HOME or MAILING ADDRESS S- ��` , `� V— L2Ot j11) <br /> CITY O W STATE Q-� ZIP C O <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,Standar STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: -� y - U y <br /> PROPERTY/BUSI\ESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 'Y�� <br /> IfAPPLICANT i not tl 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: (tST- P=E-W O E FF PAYMENT <br /> COMMENTS: RECEIVED <br /> APR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �L. I ✓'C EMPLOYEE#: C, Z/ DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: T ( 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 9 y P 1 E: 3 4 <br /> Fee Amount: --2-7.9 .IDO Amount Paid '?.— Payment Date y — <br /> Payment Type Invoice#,a-� Check# R ceive By:kL�k <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />