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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> i <br /> 1( 2- �S rZ Ga(' y 1.3 I �� <br /> dWNER/OPERATOR <br /> CHECK if BILUNO ADDRESS <br /> (/fir <br /> FACILITY NAME W fi�(O O FO O d 4- �i I <br /> SITE ADDRESS �tr I n D �a Y <br /> ��s <br /> Street Number n W t N me C � <br /> HOME or MAILING ADDRESS (If Different fromSite Address) 4,_0"'' <br /> 114 <br /> Stree7a. r Strwt Name <br /> CITY J _ STATE ZIP <br /> til b <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (M) -SSltn � -140--30 _ T <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> (20 Flo _5_( 1 61-)C, <br /> 11 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILUNG ADDRESS❑ <br /> bLwak' by, <br /> BUSINT N E PHONE EXT. <br /> i V►P.eri' -2-0) <br /> HOME or MAILING AW &i <br /> �Q, ,� FAX# <br /> CITY 6 STATE(fi Zip q52 <br /> D 2 <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 lakes./ <br /> r APPLICANT'S SIGNATUM: CA---qC4 s,I " DATE: 2- 7-��— <br /> PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCAw is not the BILLlNGPARTY proofof 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 environm�eCntal/site assessment <br /> a[ <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is av the same time it is <br /> provided to me or my representative. Pi� /VED <br /> TYPE OF SERVICE REQUESTED: IC— <br /> COMMENTS: <br /> SAN JQAQUIN CpL� <br /> ENVIRONMEN ENT <br /> N�LTH DEPARTM <br /> ACCEPTED BY: EMPLOYEE M. DATE: 0 <br /> ASSIGNED TO: �� l S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P/E: 7 <br /> Fee Amount: 7 Amount Paid 45 a 7q. Q Payment Date .7-W O fj <br /> Payment Type �� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />