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• Stsal MACQUT—TCOMY <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE <br /> Ser v 1 eL JCO? <br /> OWNER i ERATAR <br /> U TT' re �e u �)� CHECK if BILLING ADDRESS <br /> FACILIrI M' JrC,�,1 S`T(C <br /> SITEADDRESS Y r Ie �� S�D C �v� y�ZQ <br /> a-10 S Street Number Direction ou t` Street Name Ci Zi Code <br /> HOME Or MAILING ADD SS If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE EXT. APN# LAND USE APPLICATION# <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE TOR CHECK if BILLING ADDRESS <br /> a.-�hteem flenE"tJ <br /> EXT. <br /> BSIV <br /> USIN A pH N <br /> HOME or MAI A 0 RMs/r2 e' 'sI c �)TSP <br /> CITY STATE 64 ZIP �dS-&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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: v� DATE: <br /> I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ek <br /> IfAPPLJCANT is not the BILLINGPARTY,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: <br /> COMMENTS: <br /> JAN 1 1 2006 <br /> ENVIRONMENT H LTH <br /> ACCEPTED BY: EMPLOYEE#: 2 <br /> ASSIGN DTO: C EMPLOYEE#: ,QZ�Q DATE: ( // <br /> IDAM1440ce Completed (if already completed): SERVICE CODE: I 1 P/ <br /> Fee Am n so Amount Paid \ 0 ,S Payment Date <br /> Payment Ty S Invoice# Check# $$0 Ob Recei y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />