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SAN JOAQU1N COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ps �C-ATLO N z/ S � <br /> OWNER/OPERATOR <br /> 0S A CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS L, 3 S 1 k 6—C <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> DD <br /> 1 b CL Street Number Street Name <br /> CITY �-, �^ STATE CA ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> CHECK if BILLING ADDRESSIR <br /> BUSINESS NAME 1 .1 PHONE# <br /> JC�Jv . ti1 � gExT. <br /> �Q1� 1 <br /> HOME or MAILING ADDRS FAX# <br /> CITYb�4e 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 1 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: �1. � , �,° , �� LCQt.{,41 d� i,� DATE: <br /> (( t i ��. r�,woo ��� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTLILco U.-bbaf', d (2C-f-,r <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tulg <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator �� Frtc�t€ � t the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or ronmontal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and,�teF aMg8ne it is <br /> provided to me or my representative. 1 Uu <br /> TYPE OF SERVICE REQUESTED: �(,( ?.\11 "x}�I'LI "' L <br /> COMMENTS: 64 dv q BVI v YJO • l�"j ��� ,�I I p n �" <br /> 2008�t/ <br /> ��Ery�PgRN gCN�Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 1 Amount Paid ` s 6 Paymen Date \` ZS 6 8 <br /> Payment Type Invoice# Check# ZS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />