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SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPAItTNiEN''T` <br /> SERVICE REQ EST - <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> Cf �(o J x,200 <br /> VNER/OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS {y' <br /> V <br /> umber rection eel 0mo s <br /> HOMEo AILING DDRESS (!f Diff t from Sit ddress) <br /> Street Number street Name <br /> CITY STATE zip <br /> PHONE 01 a APN# LAND USE APPLICATION# <br /> -35 <br /> PHONE#2 ExT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CNrCx if Bil i ING AC7bf2E35 <br /> BusmEss NAME t <br /> NOME Or MAILING ADDRESS FAX <br /> � Ll e <br /> CITY STATE ZIP (!� <br /> -TT,LING ACKNOWLEDGEMVNT: I, the undersigned property or business ownler, operator or authorized agent of same, <br /> .lowledge 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 idcn ified on this form. <br /> I also'certify that I have prepared this a on an the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CbUNTY ordinanee Codes,Standar an ERA aws. <br /> APPLICANT'S SIGNATUELt: DATE: ' <br /> PROPERTY/BUSINESS OwNEIk❑ PERATO / OTHER AuTHORmED AGENT <br /> IfAPPrtG1NT is trot th $ILLINGPARTz:proof of authoti2atiott t#sign is require Title <br /> AUTHOMZATION TO RELEASE IN)P'ORMATION: 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 Insults, geotechnical data and/or enviroumental/site assessment <br /> infomlation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sarne time it is <br /> provided to me or my representative. (� <br /> TYPE OF SERVICE REQUESTED: ENT <br /> J ;' <br /> COMMENTS: Jam; C--, -7-2p— RECEIVED <br /> l <br /> AUG 2 2005 <br /> 1 l6`?"fe SAN JOAQUI COUNTY <br /> ENV ON ENTAL <br /> RTMENT <br /> AGE <br /> GPTEO 13Y. EMPLOYEE EMPLOYEE 0: DATE: <br /> ASStGNED TO. —% EMPLOYEE#: 41� DATE: <br /> nate Servic®Completed (if already completed): SERVICE CODE: P I E <br /> Amount- ,...'..: ` Amount Paid, ga D payment Date. <br /> -if DS <br /> Payment Type V'° Invoice# Check# S 2Z3 Receiv By: <br /> EHD 48-02-025 SR FORM(Golden I20d) <br /> REVISED 11/17/2003 _ <br />