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SAN JOAQU OUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST ' <br /> pe of Business or Property FACILITY ID# 1, SERVICE REQUES/T# <br /> �l <br /> 9 <br /> p1 P <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACiIiTv NAME Y-rt <br /> _2 tft 1 <br /> SITE ADDRESS � � PEJIM1' Wc9k <br /> � c e <br /> Street Number Irectlo e e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �— Street Number Street Name <br /> CITY STATE ZIP <br /> Ext. <br /> PHONE#1 AIN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BIDS DISTRICT,6— LOCATION CODE <br /> .,J <br /> ( D <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUESTOR \\l/�A CHECK If BILLING ADDRESS <br /> y y` <br /> PHONE# Err. <br /> BUSINESS NAME <br /> =FAX# <br /> HOME or MAILING ADODRESS �`. \N_ ��.--�-- <br /> `J �'\ \ STATE ( ) <br /> CITY 0-1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busines0' EAVS100ciated <br /> rized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAMT with this project <br /> or activity will be billed to me or my business as identified on this form. e YQ <br /> I also certify that I have prepared this application and that the work to be performed WI e o IPcbrdance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. ENVIRONMENT HE iTLI <br /> n <br /> APPLICANT'S SIGNATURE: \ �0. ( PERMWARVIG <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT lJr (1\ C=L-s\- " 5!— <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 JOAQUTN COUNTY ENYTROr.TNmNTAL 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: LtS T— 4C71" <br /> COMMENTS: — "') <br /> f <br /> � 9,1f C�V <br /> ACCEPTED BY: ®�t �f� t <br /> LJ\VMPLOYEE#: 0 '� -Z DATE:ter" C Q Q <br /> ASSIGNED TO: /� A N G OYEE#: '� � DATE: <br /> Date Service.Completed (if alreq6y completed): Sp`N N\J tRoNpPP�Mr SERVICE CODE: ��8 P i E: 2.1 <br /> U cQ <br /> Fee Amount: E S° Amoun Payment Date ��l t <br /> Payment Type Invoice# Check# lf3t f/0 8 Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/1712003 <br />