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SAN JOAQ*CouNTY ENVIRONMENTAL HEALTSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (� 1'--,4 oCCo 7 y ��CC Z//s5-3 <br /> OWNER/OPERATOR <br /> a CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> SYNumber Direction Street Name C Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> off() -k75Atb <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK if BILLING ADDRESS <br /> B I SS NAME �.�\� \ PH E.T. <br /> C:f -7 <br /> HOME or MAILING ADDRESS FAX# <br /> Ll(�Ed -4 COI Q <br /> CITY STATE cp, LP G12 <br /> BELLING 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 ' application and that the work to be performed will be done in accordance with all SAN JOAQurrl <br /> COUNTY Ordinance Codes,Stand ds,STA and FEDERAL I ws. <br /> APPLICANT'S SIGNATURE: VDATE: �` <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is requireu 7 <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 JoAQu1N CouNTY ENvmoNmENTAL 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: y <br /> COMMENTS: <br /> "qW MAR 1 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L-i i f� EMPLOYEE#: DATE: <br /> ( s ZI 31 1-51C,5 <br /> ASSIGNED TO: L,,v ,J F EMPLOYEE#: P3/ 7 DATE: 7� / s <br /> Date Service Completed (if already completed): SERVICE CODE: / 0,, PIE: <br /> Fee Amount: el,LL) Amount Paid I Payment Date <br /> Payment Type ,/ Invoice# Check# 602 79 39 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />