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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH 'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4 5htwo✓� � r ��,5 �o r .� e �7 S,to_ao l/f 2y3 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> c t%t� bdt,�fs <br /> FACILITY NAME <br /> P v✓D 1i <br /> SITEADDRESSW,,le/ l0,3 /CO3 _l <br /> / J Street Number I Direction Street Name aG Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 9630 <br /> ( ib ) CATION CODE y OPH NE#2 BOS DISTRICT 6-1 65 . <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,,L(,xundtt,@ vie s­�_C. cam <br /> /ne /Pwdi, P✓ J C 2r CHECK BILLING ADORES <br /> BUSINESS NAMEW11 t4 Ae /' PH'tl/#O 66 96 lac,.�^LExi <br /> Gl <br /> HOME or MAILING ADDR S FAX# <br /> (9/b) k4 96 6 <br /> CITY �C✓Gm STATE ZIP 4S 6 <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. 1 �/ <br /> APPLICANT'S SIGNATURE: DATE: 9?///Y> <br /> PROPERTY/BUSINESS OWNER❑ eILLING <br /> TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not t 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 Ftime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RAD e6 <br /> COMMENTS: SAN JO 2014 <br /> Ely gQ1J1 <br /> HEACTH DE Aq Tq�N�Y <br /> MFN�, <br /> ACCEPTED BY: ) � EMPLOYEE#: ­2 DATE: <br /> ASSIGNED TO: 3-6 I,,j EMPLOYEE#: DATE: <br /> Date Service Compf ed (if already mpleted): SERVICE CODE: (� PIE: <br /> Fee Amount: 13' ---- Amount Paid 75-.6D Payment Date / <br /> Payment Type Invoice# Check# 3L:b7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />