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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTWPARTMENT <br /> SERVICE REQUEST <br /> T pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Q�r- I e u M � r —�- % Oh CHECK If BILLJNG ADDRESS <br /> FACILfrY NA <br /> a 5 13 <br /> SITE ADDRESS W n h e- Lod 5Q q,) <br /> 01 Street Numtwr Diree fon Street Name Cft Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) a n c h �n � b <br /> 9 05 Street Numtwr Street Name <br /> C S ATE ZIP <br /> PHONE#1 Exr. ApN# LAND USE APPLICATION# <br /> (acs ) a Iy-graoo <br /> PHONIER Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> UESTOR <br /> CHECK if BIWNG ADDREssin- <br /> . <br /> BUSINESS N d P"°IiE# En <br /> Spra h 5 $5 815e <br /> HOME or MAILING ADDRESS <br /> Fax# <br /> 303,4 N. -1 cam.._. l t5Sq) 35-- Q q q 9 <br /> CITYr&d vJ STATE l a ZIP 9 3'�-3 J <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,STATE and FEDERAL laws.,Jf <br /> APPLICANT'S SIGNATURE: ECl S DATE: <br /> PROPERTY/BUSINESS OWNER OPERA /MANAGER D OTHER AUTHORIZED AGENT D <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 an same time it is <br /> provided to me or my representative. %� M E N T <br /> VrZU <br /> TYPE OF SERVICE REQUESTED' � ;S �'1 <br /> COMMENTS: APR 13 2005 <br /> 1�?i-LMQ �a4 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �L'x EMPLOYEE#: t;K16DATE: (q <br /> ASSIGNED TO: 't'• EMPLOYEE �? bc) DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t PIE: a <br /> Fee Amount: r f✓L Amount Paid .2 Payment Date /� 46, <br /> Payment Type ✓ Invoice# Check# _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 A/ <br /> J <br />