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f <br /> SAN JOAQUIN COUNTY ENVIRONME,11-AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5,12o b 4 /� S-9 <br /> OWNER/OPERATOR j L-L CAf1-(,5arJ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 12_ / <br /> SITE ADDRESS l NPN <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I`zs" UuDSb,1 Afilze)44 <br /> Street Number Street Name <br /> CITY Sm/iV STATE Ablw ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( -710 ,'- Z -,r 06?- z6o - 0-3 , vy ;moi+ - 6t, e� T2s <br /> [PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADORE <br /> M I K6 7U-1 <br /> BUSINESS NAMEPHONE# EXT. <br /> r?l (-2w 33y- &6/3 <br /> HOME or MAILING ADDRESS FAx# <br /> (2,69 , 33Y-o723 <br /> CITY L�r' STATE (- ZIP 9Szy / <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: —7 O S <br /> PROPERTY/BUSINESS OWNER OPERATOR/TIANAG OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT 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: <br /> COMMENTS: <br /> 7 2005 <br /> /rG77U COUNN <br /> (iii!/i,JJ SAN JOAOUINENTAL <br /> ENVIRONM nr-PARTMENT <br /> ACCEPTED BY: �LI �i�i Vert EMPLOYEE#: C);>2 I DATE: 7 P-S <br /> ASSIGNED TO: ;A-I f} EMPLOYEE#: S-5 (j lL DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 j S P 1 E: �,.C,3 <br /> Fee Amount: OAmount Paid Payment Date 3 (- <br /> Payment Type Invoice# Check# 10 — Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />