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SAN JOAQUIN _JUNTY ENVIRONMENTAL HEALTH _ -PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .r Pt 00 2.Z(0'95 45 f2 0011UV_j <br /> OWNER/OPERATOR )OC�� J _ IoS n /\ /kALe3 �-1J� -;> E KifBILLINGADDRESS❑ <br /> FACILITY NAME C1�2t�t�I I� �c <br /> SITE ADDRESS e—vl VA <br /> Street Number Direction Street Name T City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -:31 LA to <br /> Street Number Street Name <br /> CITY STATE ^ ZIP a s'L f 2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z()`'I ) �q co— 3llj S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE UE TO <br /> rJAe <br /> t C6 ;kv� SPS Co[&;IL Fal C CHECK If BILLING ADDRESS <br /> BUSINESS NAME (ij i ( /J� ��Ii I� �A In O L �, ,CIV ,qT 3I�� PH NE � ^0— �3 EXT. <br /> HOME Or MAILING ADDRESS L4 ( 1 4t� d1 ih �j FAX# <br /> CITY STATE O 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 <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, ST an DERAL laws. <br /> APPLICANT'S SIGNATURE:PP DATE: 0 <br /> PROPERTY/BUSINESS 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, 1, 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 anPAYfMJ ne it is <br /> provided to me or my representative. ( rRECEIVED <br /> TYPE OF SERVICE REQUESTED: -MO �/Q:��L C�Q 1 YI� f.h1 �,��� <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> UUU ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,1 V lwi y l V EMPLOYEE#: DATE: 01_�3-Z-0 <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: bu l P 1 E: 03 <br /> Fee Amount: '* l GJ2 0 1 Amount Paid Payment Date P— <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />