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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH*PARTMENT <br /> ,SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 3 7/7 SERVICE REQUEST# <br /> OWNER/OPERATOR l CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> C� �v✓o � _ <br /> SITE ADDRESS I-A3 4141 joe3 n ����(/lO.•t <br /> Street Number Direction Street Name city 2i Code <br /> HOME or 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 /> (lir ) X7.3/ -Z-/8c <br /> PHONE#2 EXT• BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Gam` CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESEr FAX# <br /> CITY S' .3 F <br /> IG'.y�i d �l d STATE C5��1 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ✓'y'C•�. C `l <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. <br /> TYPE OF SERVICE REQUESTED: LC S 7— !e-�F-7-0-ca F t <br /> COMMENTS: <br /> U6/10-1 14ya" <br /> JOPOUN N�A�� <br /> �X�pEPAA�Er'T <br /> ACCEPTED BY: O( L V1 IQ EMPLOYEE#: 03 Z/ DATE: <br /> C1� <br /> ASSIGNED TO: ' „ ! EMPLOYEE#: DATE: ll <br /> VV r t ` <br /> Date Service Completed (if already completed): SERVICE CODE: l T P 1 E: o8' <br /> Fee Amount: 3&& ,c-i) Amount Paid 3140(111_ Payment Date ( l t <br /> Payment Type Invoice# Check# Received By: 2yl/ <br /> EHD 48-02-025 L �'— SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />