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d8/18/2005 09:01 203433 EHD PAGE 01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTR DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It <br /> R V t 2 13 b SERVICE REQUEST 9 <br /> OWNE /OPERAT <br /> �W` CHeCK l r I t <br /> PAC UTY NAME <br /> SITE ADDRESS 1 •� <br /> Stool Numb' Ou etlo "''"� WED <br /> C� <br /> HOME of MAILING ADDRESS fir Different from Site Addraaa) o N <br /> cI I co 0 <br /> Ci ry 31roet Num <br /> R it Nama <br /> STATE ZIP <br /> PHONE 11 ,. <br /> I ) APM 9 <br /> LAND USE APPLICATION <br /> PHONE#2 En <br /> ( ) BOS DISTRICT p 7LQCATTIO�F,p,. CONTRACTOR/S RVICE-REQUESTOR <br /> REOUESTOR <br /> t CHECKIf <br /> ADDgEta <br /> BuswEss NAMEQ C <br /> PHONE# [O EXT. <br /> Hoar:or MAILLNG ADORES <br /> FAX tt <br /> CITY <br /> STAT` ZI <br /> BULLING ACKNOWLEDGEMFNI: I, the undersigned property or business owner, <br /> acknowledge that ell site and/or project specific ENVIRONMENIAL HEALTH DEPARTMENT hourly charges associated w hnthiof same, <br /> s project <br /> or activity wit) be billed to int or my buslaess as identified on this form. <br /> I also Certify that I have prepared this a ation and that the work o be rformed will be done in accordance with all SAN JOAQurN <br /> COUNTY Ordinance Codas,STandardr 7A and FLDERAI,taws. <br /> —._._ <br /> PLICANT'S SIGNATURE: <br /> DATC: I t/ <br /> �P�P011IL%T0.R/MnnAGER ❑ <br /> (7T nEA AtlT'HOIiiSEo ACENT❑ <br /> /f APPUCdNT is n nri1OdOn 10$J:A is required <br /> AUT OWZATION 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 env iron niental/s ite assessment <br /> Inform cion t4 the SAN 10AQUIN COUNTY ENVIRONMLNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided 10 me or my representative. <br /> TY�SERVICEREQUESTED: �L L F C.T R 'V' <br /> sA NOV 1 3 2nnv <br /> N'J0AQUIIV co <br /> � NEALTy pFP Nq�7.v . <br /> ACCEPT @DHy: <br /> t P2 EMPLoyar C <br /> C'.� .Z-( DATE: C'� <br /> C. <br /> E'Arfy"M: 2- &7 C DATE: <br /> 41 <br /> Data Service Completed (if alr►ady completed): l/ C^ <br /> SERVIee CODE; I G r— P 1 E: <br /> Fee Amount: AmountPaid <br /> I fes' 3S r ob Payment Date <br /> Payment Typo t� Invoice p Check if <br /> S ?-0 �o Received By: Flyr_ <br /> EHD 0.02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Roa) <br />