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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F ID <br /> 601*41E2c(A L <br /> OVWER i OPERATOR <br /> 11112 , WA LT—,—/Z /A-9�IIVED O / C <br /> ft- <br /> AM <br /> FAciurYNE F �(� .7– <br /> K ��M/V / N <br /> SREADDRESS 1nC755P,41-,E- <br /> D 1" Num be DVectbn Sup"Narm zip cy <br /> HOME or MAILING ADDRESS (if Dliferent from Site Address) <br /> Sheat Numbor Sbvet Nanw <br /> CITY A Tf l2 0/ STATE CA vo <br /> PHONE#1 E"t- APN# LAND USE APPucAw..4# <br /> { ) <br /> PHoNE#2 Ext. BBS Dtswacr LOCAnoN CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTUR <br /> REQUESTOR O <br /> Ch)ECX M NC,ADotiEas C7BUSINESS NAME , PHot€I Em <br /> l0 8-/ <br /> HONE Or MAl1JNG ADDRESS FAX* <br /> CITY Z4 R I—ace <br /> STATE 4�1ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property cr business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMFWAI.flt''ALTH 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 applic ion and that#e work to be performed will be done in accordance with all SAN JOAQUIN <br /> Coumry(hdinonce Codes,Standards,ST and FEDF ywS. <br /> APPLICANT'S SIGNATURE: 1Z^ � — Q'¢ <br /> DATE' <br /> PROPYRTY/BUSINESS OWKXR❑ OPERATOR I MJIGER13 ER AUTROR:ZED AGPNY <br /> If APPLICAAri,is not the BiLLnva PARTS proof of autho station to sign is required Titre <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 re!ease of any and ali 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 i5 <br /> provided to me or my representative. <br /> Ju— <br /> TYPE OF SERVICE REQUESTED: " <br /> COMMENTS: tl <br /> z/31c�/ � �/ `- DEC - 2 2004 <br /> SAN JOAQUIN OEfMRONMENTAL <br /> 9EPARTMENT <br /> ACCEPTED BY: EMPLOYEE$: S1 ( DATE: <br /> o <br /> ASSIGNED TO: ( EMPLOYEE 9: DATE: <br /> Date Service Completed (If already completed): 2,/3/e, <br /> / fj`/ I SERVICE CODE: P!E-- <br /> Fee <br /> Fee Amount: ! Amount Paid �L101 -- Payment Date —a —D <br /> Paym&nt Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />