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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D1;PARTMENT ,7f2�V WL'-5/0 <br /> SERVICE REQUEST <br /> ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ` PAYMENT ' `-(C <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> IAN InArl,I'm C-01 INTY <br /> SITE ADDRESS ^ ENVIRONME TAL <br /> :�EALTH DEPARTMENT' <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> LPI A�- <br /> X(-Pi1VC Street Number greet Name <br /> CITY STATE ZIP <br /> Legit, =-�'' L� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> yC) 6�-7— Zit. t, --- <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOCHECK if BILLING ADDRESS x <br /> W <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS <br /> z 6' ) 33 1-6�z-5` <br /> CITY �� k0 ) STATE ZIP y� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, C <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. (f� <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 SIGNATUREDATE: <br /> PROPERTY/BUSLNESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT / <br /> If 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 environmentaVsite 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 W t t ! tOS,,% <br /> COMMENTS: Y <br /> o✓3s�Gt/ -7t�� v .S`G'tC 40icrj e 0C� 1CC)4L, - 7D.J "7-Z� E i f <br /> US 1 � <br /> D T� �O lLli% <br /> 1— S- /4 C-€ <br /> 64e6-r;v <br /> ACCEPTED BY: L EMPLOYEE#: ( j Z! DATE: / f /C' <br /> Ass!czNEDTO: t.� 1L, EMPLOYEE#: DATE: % /G' nC <br /> Date Service Completed (if already completed): SERVICE CODE: G& / P E: 2--�Z- <br /> Fee Amount: I ? Or7 Amount Paid 'F Payment Date <br /> Payment Type Invoice # Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />