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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> II/ Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i OWNER/OPERATOR <br /> /UN �u G CHECK If BILLING ADDRE55O <br /> FACILITY NAME �C s <br /> i <br /> w <br /> �. <br /> SITE ADDRESS ^)719 <br /> Street Number irection Str..t Name city Zip Code <br /> II HOME or MAILING ADDRESS (If Different from Site Address) <br /> U boy 6 q 15 Street Number Street Name <br /> CITY STATE ZIP <br /> 5`ot_12s G '95-7-e, <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (1-7) <br /> PHONE#2 EV. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R <br /> REQUESTO <br /> �IJ O ( Seo It�.IG CHECK if BILLING ADDRESS <br /> BUSINESS AME/\/` PHQQNE# it'' <br /> nAPQ�T Pc l2 l..J L� -�roC1 <br /> HOME Or MAILING ADDRESS FAx <br /> o too (Zo )ob? <br /> CITY C OC STATE ZIP <br /> L -13ILLING ACKNOWLEDGEMENT: 1, 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,STand FED RAL laws. �t <br /> r (-ZAPPLICANT'SSIGNATURE: L" DATE: t2c-) <br /> PROPERTY/BUSINESS OWNERS, OPERATOR/MANAGEROTHER 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sarp jilne it is <br /> provided to me or my representative. / M T <br /> TYPE OF SERVICE REQUESTED: o 0 P(G V C <br /> COMMENTS: t O <br /> E JOAQUIN COL <br /> HZ66JAM-H 1) NTA <br /> TMT <br /> ACCEPTED BY: r^^, r� c, EMPLOYEE#: DATE: 'L�� <br /> ASSIGNED TO: 1 /V.1 EMPLOYEE#: DATE: <br /> 1111 CCC!!! �-v r <br /> Date Service Completed (If already completed): SERVICE CODE: S•Z� PIE: <br /> Fee Amount: Amount Paid 3QL+,— Payment Date <br /> Payment Type Invoice# I!� /n�r�1� p1 Check]# Received By: <br /> EHD 0172003 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />