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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY^ SERVICE REQUEST# <br /> 7 <br /> vv , <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILrry NAMV.�V✓ �+ (JCS C a✓�'�/I L, 7/�4,1/���L•� <br /> SITE ADDRESS (— tAl <br /> Qa etNumber Direction Street Name Zip Code <br /> HOME of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ,Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> vor y;'W-46-0 y9 <br /> PHONE R ExT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Z�/'//y CHECK if BILLING ADDRESS <br /> /7 L7 G C: PHONE# EXT. <br /> BUSINESS NAME 'I1�%C y�C <br /> HOME Or MAILING ADDRESS FAX# <br /> �o <br /> 11y46:;5/4V C-eccc ` y c,�l 3107 <br /> CITY STATE 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 <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,STA d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ia. > DATES: D�11,P 7/,Z(9060 <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ElTtmg AUTHORIZED AGENT U/LFaAvW-*e-T02 <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Tate <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 ENvIRoNMENt'AL 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: <br /> COMNENTS:��� �C <br /> /� JE c✓ c /" IIIrfDD) <br /> 11ENVIp�N E OUN7y <br /> P4Tr' <br /> ACCEPTED BY: EMPLOYEE#; v <br /> l : <br /> ASSIGNED TO: EMPLOYEE#: I, <br /> Date Service Completed (if already compteted). SERVr-ECMEE: PIE: <br /> Fee Amount: Amount Paid - 2 Payment ate <br /> Payment TypeInvoice# Check# 77- R"ved y: <br /> EHD 48-02-025 SR FORM(G den Rod) <br /> REVISED 11/17/2003 <br />