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SAN JOAQUIUNTY ENVIRONMENTAL HEALT�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAS 0003bFV) S'a-Uc�3t�S3 <br /> OWNER/OPERATOR <br /> L-0 D l 1-00 D L- ( C f � © � ` ' �' C CK if BILLING ADDRESS <br /> FACILITY AME ( F-00 D �l�o g lO/ <br /> SITE ADDRESS /✓,�//l V ��//� <br /> Pla-s Street Number Direction Lp V e-E-r a t P..?-� � city <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> 045q) 333 1033 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 13 P_1 J+A) -ri�KA-) 6 ) <br /> BUSINESS NAME f�/ CHECK If BILLING ADDRESS <br /> PHONE EXT. <br /> cf-oT'60 " SvA-) AFL-C'C-T�2,/ <br /> HOME or MAILING ADDRESS FAX# <br /> P,0 , 3(00 83 ) <br /> CITY I L P LT/+-s STATE CA zip <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:—/I DATE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER 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 same time it is <br /> provided to me or my representative. ENT <br /> TYPE OF SERVICE REQUESTED: k)GC q5!5NqJ--.)V—T"K" RECE� <br /> COMMENTS: <br /> covNn <br /> SA EN�PONMER NAIENT <br /> HEALTH DEPA <br /> ACCEPTED BY: EMPLOYEE#: f)-AS-3 DATE: l 1*--L1,0kA <br /> ASSIGNED TO: EMPLOYEE#: 53 DATE: ` 0i <br /> Date Service Completed (if already Completed): SERVICE CODE: `� PIE:cZadl:� <br /> Fee Amount: Amount Paid -1� Payment Date Lf <br /> Payment Type Invoice# Check# �� Received By: LE <br /> EHD 48-02-025 SR FORM(Golden R� <br /> REVISED 11/17/2003 <br />