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1 ! R <br /> SAN JOAQUOUNTY ENVIRONMENTAL HEALT*;�'ARTMENT <br />' SERVICE REQUEST <br /> Type of Business or Property G'p U / auJA.'crD FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> -5" J o A( a&)I , / CD 0 CHECK if BILLING ADDRESS <br /> FACILITY NA /T G�L! /1 AJ U U D CDlQ / <br /> SITE ADDRESS / I q 7�' 4L16 . S-110 etenA) TqS: <br /> "Z e� <br /> Street Number DireCUon /T�?is Street Name C Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / Street Number Sbyet Nam <br /> CITY � STATE� ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) 4Q?— 3/D6 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J 15Ss6 66-A 0/0 e/V <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 13,464,!51V <br /> /d64,! 5�KJt6) a C—'.5 /A)I:f' PHONE# Fn. <br /> HOME or MAILING ADDRESS FAX# <br /> 6[ '� ) <br /> CITY /—N/I ( STATE C+d ZIP qc-2110 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, o`peerraa'tor 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR(MANAGER ❑ OTHER AUTHORIZED AGENT ("���` Q� S <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title PA <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property tT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUSite asse�VRkD <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thAWe f rhe $0 <br /> provided to me or my representative. r,�S r{ Sq <br /> TYPE OF SERVICE REQUESTED: ✓J S'f (/M/© �Q G tQ S HE 4�TVIREPAR44."U <br /> COMMENTS• 96104-14 IMP 000rAT 87 UNL-64.0E0 91-P 10/10m)a <br /> U,jlA-'& srct4 peOti,R �v P. <br /> �N S�<'1L i Co <br /> Pt .,✓6 Sal -Q 19,,6-S6-L, AQo')N,p Le i{ C04ZA/ 14'" cl- <br /> P P � <br /> P'r-P 5- Aq--f Ar A.) °t a P4SS 1-44*6 mss- <br /> ACCEPTED BY: C) (v E EMPLOYEE#: 0-'�Z f DATE: <br /> ASSIGNED TO: i,��Q 1'JEMPLOYEE#: C, l-k%eI DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: (1?k P I E: 2-3a k <br /> Fee Amount: 3 L 4 ount Paid 3 2 Payment Date O <br /> Payment Type i S Invoice# Check# -1a3b I.,Lib � <br /> Received By: (v <br /> EHD 4&02-025 a 4 1 1 3�b SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> I <br />