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SANONMENTAL HEALTHOP <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: <br />�( # VS0612jr <br />4 eS'06ILI v S <br />r <br />FACILITY D # <br />BUSINESS NAMEh <br />SERVICE REQUEST # <br />646 S� <br />( -7 <br />r)9 bbbp sg <br />HOME or MAILING ADDRESS <br />lob? 40 <br />2Q2w/6a" <br />�' r <br />SERVICECODE: <br />CITY G <br />L e <br />STATE C4. <br />Zm <br />OWNER /OPE R <br />�L' <br />Payment Type 1Z <br />Invoice 8 <br />CHECK if BILLING ADDRESS <br />e <br />Y <br />T <br />FACILITY NAME <br />yy, <br />„ „4 <br />SITE ADDRESS /) 3 o <br />m >7 L- S), <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi e <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE LP <br />PHONE #1 <br />Ezr. <br />APN # <br />LAND USE APPLICATION # <br />(�b�1 3 L 3 -2-3 3 <br />PHONE #2 <br />Exr• <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: <br />�( # VS0612jr <br />4 eS'06ILI v S <br />r <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEh <br />_ , G 1/ <br />/` <br />DATE: /.. J <br />( -7 <br />_ / l /� <br />�i S <br />HOME or MAILING ADDRESS <br />lob? 40 <br />3 <br />FAX # <br />(7D 7) <br />SERVICECODE: <br />CITY G <br />L e <br />STATE C4. <br />Zm <br />BILLING 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 }burly charges associated with this project <br />or activity will be billed to me or my busuess 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 TE and FEDERAL laws. <br />APPLICANT'S SIGNA7'URE: ll:1TE: ��✓�� d <br />PROPERTI / BUSINESS 0%%NERf OPERATOR / MAN:\(: OTHER AU'I HORIZED AGENT ❑ <br />i/'APPLIC. I \T is not the BILLING R I RT)'. 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 avai,L@)� a"Tsame time it is <br />provided to me or my representative. tpt-- 11�''IVED <br />TYPE OF SERVICE REQUESTED: Z4 S L ne !� <br />COMMENTS: <br />�( # VS0612jr <br />4 eS'06ILI v S <br />r <br />SAN JOAQUIN COUNTY <br />ENVIFIONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: /.. J <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: /o <br />Date Service Completed (If already completed): <br />SERVICECODE: <br />PIE: <br />Fee Amount: �$ 74q, r u Y <br />Amount Paid <br />l l t 0-b <br />Payment Date `� 3\ 5 <br />Payment Type 1Z <br />Invoice 8 <br />Check # <br />Received By `v <br />EHD 48-02-025 SR FORM (Golden Rod) <br />011\�� <br />REVISED 11/17/2003 <br />