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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTjT DEPARTMENT <br /> SERVICE REQUEST 0 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Q< 1' / �' �- 3 S(2 00 S 3,53 <br /> OWNER/OPERATOR <br /> Y�^ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS (J��'�/`,°°�� ( � v265 <br /> Strektl�iumber Direction t�l Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 23V l v <br /> PHONE#2 EXT. BOS DISTRICT j LOCATION CODE <br /> ( ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �{ [� PH EXT' <br /> E&l c ( V �o� � s E E (,3 3 7 <br /> HOME or MAILING ADDRESS / � FAX# <br /> '4'5'3 '5 (,.t./l k-x lm be- r ( 6 !- t!P 3 a <br /> CITY S (_ G k 1 STATE n R 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 or <br /> 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,Standar STATE and FEDERAL laws. �y <br /> APPLICANT'S SIGNATURE. r Q DATE: 17S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT�J p �r�/ G is C�0Q 0�f ha-4� <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: �S f �� <br /> COMMENTS: fl/ I D <br /> SgNoO /J �U(1 <br /> Fiy�qQU/ <br /> y�CTyFPgHT, 7Y <br /> MFNT <br /> ACCEPTED BY: ©L-t V I EMPLOYEE#: 2—/ DATE: 3 <br /> ASSIGNED TO: `/L�i V <br /> EMPLOYEE#: Oc5e) / DATE: 3 S C)e <br /> Date Service Completed (if already Completed): SERVICE CODE: ! P 1 E: ? <br /> Fee Amount: —4 Z-9 Lf. I <br /> Amount Paid C ,cam Payment Date 3 J S 3 g <br /> Payment Type �, Invoice# Check# 2(0ck I.A Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />