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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 1111 <br /> Type of Business or Property FA VILITY 110 TM <br /> OWNER/OPERATOR `\\ D o <br /> CHECK if oILLIriG ADOkESS <br /> FACILITY NAME � /� �{ ' ` //� <br /> SITE ADDRESS rn /.�} <br /> I i L/l�� /V �J rnI/C�I//, fvv�IIIY�JI V I '// <br /> I'Street Number Dire ti Street Name an Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> njwZ L- / ) Street Numb- Stteet Name <br /> CITY STATE ZIP <br /> MA-Al LEE CA <br /> 2S-3:14 <br /> NONE#t � t � � � APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME GL L G /r ( PHONE# Z 3 �2 9/ <br /> HOME or MtuUNG ADDRES FAx# <br /> Y 1 ) <br /> CITY STATE G zIP 9 ? 3 <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 ormed 'll be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUjgE: DATE: <br /> PROPERTY/BUSINESS OWNERR}CJ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required T i r l c <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 asses pe t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tip71y g4'. n <br /> provided to me or my representative. R �)v r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: c/ t% L r <br /> SEq TN <br /> 12020 <br /> l� HJ0,4QCOL/ <br /> qLR PFN� <br /> NT Y <br /> RTMFNT <br /> ACCEPTED BY: EMPLOYEE#1 DATE: 01 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already mpleted): SERVICE CODE: Cl/• P i E 14 O <br /> Fee Amount: 1, Amount Paid Payment Date77 <br /> Payment Type _ Invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> NON low <br />