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SAN JOAQUI BOUNTY ENVIRONMENTAL HEALI )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t►� �� S�0 v q� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> IIA <br /> D n <br /> FACILITY NAME le iU� (`✓ (b\ C? / Plg- -7L, D 02 J <br /> SITE ADDRESS 1'1 1 (_ f' (�L 1e, fvl A C,ft 9 �3 1 <br /> Street Number Direction 'L3 E Street NamCi Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> ExT. APN# LAND USE APPLICATION# <br /> ( d v-1) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RF�QUESTOR CHECK if BILLING ADDRESS❑ <br /> A t--, IN,-, I ' <br /> PHONE# Ems' <br /> BUSINESS NAME l r a ` ` C� b�" <br /> S A\j C- t-- a C t r' -1 C ( It 5C lJ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY <br /> STATE C A ZIP !'�� <br /> S � '.1 <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 or <br /> 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,STATE a DERAL wS. <br /> APPLICANT'S SIGNATURE: ' DATE: 01 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not theBILLINGPARTY 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: U S–/— k� 7,I I�F I <br /> COMMENTS: RECEIVED <br /> APR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEA TH DEPARTMENT <br /> ACCEPTED BY: EI �L� EMPLOYEE M �2 r DATE: 1 sl C 4� <br /> ASSIGNED TO: 1 /o/,J F4-,,E-- EMPLOYEE#: S3 / 7 DATE: S/ <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:_Z3 , p 0 <br /> Fee Amount: ,�,;, Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: ��d�� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> DMnccn iim7rmnc - - <br />