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SAN JOAQUP `•'OUNTY ENVIRONMENTAL HEALTP ''EPARTMENT <br /> SERVICE REQUEST <br /> Type of Busi ness or Property FAa U-Y ID# SHUCE RE ESE# <br /> FOD TOG-L N c t-J 3A 06 76�6,;2' <br /> OWNER/OPERATOR n ��' j� " ' 1 f <br /> V � � ��{ CHECK If BILLING ADDRESS <br /> NAME ME " 1 O I L' M C—NtA <br /> STEADDRESS To 21 Irk I S,W k j l\/ S-racf—T O 21DI <br /> Street Number I Direction City Zio Code <br /> HONE Or NULINGADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHoNE#11 ��� 3�T APN# LAND USE APPLICATION# <br /> X12� Z <br /> PHorE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> / ) .11,12f:72 CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME ,n_ J5//6' PFiO►)� 1/ , ! Z3 <br /> T <br /> C�L <br /> HOME Or MAILING ADDRESS G FAX# <br /> .2 W. ( ) <br /> CITY STATE�A ZIP <br /> �C <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,S E and FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANr 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 saFpe,time it is <br /> provided to me or my representative. - ~I rM�^IT <br /> TYPE of SERVIcE REQUESTED: ��X I �C � JAA1 0 <br /> CCMMEN-M S48 <br /> � N p Uty <br /> �fy> <br /> ACCEPTED BY: EMPLOYEE#: DATE I <br /> ASSIGNED TO: EMPLOYEE#: DATE 1 <br /> Date Service Completed (if already completed): `RMCECoDEsC, Z P/E 1601 <br /> 6oI <br /> Fee Amount. 15 L+� Q� Amount Pa' d-d I Payment Date <br /> Payment Type ✓ Invoice# Check# !S� Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />