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SAN JOAQUI�TY ENVIRONMENTAL HEALTRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR , <br /> '�+Nl AJaCD lv�j-e L 1P CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 1,01-1-L aoll Street Number I Direction Street Name L C Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /1.^ ���r ,t!,p �-. �J j <br /> Street Number Street Name <br /> ,/L(, <br /> CITY /a-4n STATE CA <br /> ZIP q/- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 12-0 -O?-o -- UI <br /> PHONE#2 EXT. BOS DISTRICT LOCATION C(O� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORC A tt AOK� P, P�-1 \ �S ` ' f CHECK If BILLING ADDRESS <br /> "L ✓V f'( EXT. <br /> BUSINESS NAME PHONE1 3 i -- 7 y v <br /> HOME or MAILING ADDRESS 3 'T b �( /./ r �� pj I� FAX# <br /> CITY cg Z ZSTATE ZIP <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,Standards,S E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: * � "-o' Ua� DATE: 2 - - b S� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required a Titte <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 environmentaUsite 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: ��t. I `4Z(� S (p �. r� <br /> COMMENTS: R <br /> ��ay�� FEB 11 zoos <br /> SAN dOAC1UIN COUNTY <br /> �L,TH DEPART <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 { <br /> ASSIGNED TO: - EMPLOYEE#: �� DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid SIC - Payment Date ( �� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />