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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIj DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GcA�, S�C`Vl 0 r1 I WWILsg v 6 if <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME F Q �, <br /> r w 3 <br /> SITE ADDRESS )C:) Y1 <br /> T '_?S 33 <br /> Street Number Direction Street Name C" Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T APN* LAND USE APPLICATION# <br /> Zr1) Sri 91S _WS <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME — PHONE# EXT. <br /> 33 <br /> HOME or MAILING ADDRESS _ \ \ Fax# ) ��1 _��� <br /> W \ C_ <br /> CITY STATE C�}i� STATE Cl�,� ZrP � 0 O� <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,Stan ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNEl7 OPERATOR/AlANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICM�J1 is n t the BILLING PARTI proof of authorization to sign is required Title <br /> AUTHORIZATION TO ASE 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: tt_('r 4_9 �IT <br /> COMMENTS: <br /> SPN jaA0 0t4 GpUNN <br /> OvIR414ME T AL <br /> FIEP`LTN pEPNg <br /> ACCEPTED BY: 01_1 L/4e fe-4 EMPLOYEE#: �3 DATE: � � 2 q h <br /> ASSIGNED TO: , !U&) 7c4-u F_ EMPLOYEE#: r'3 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 14 5 P!E: <br /> Fee Amount:f;p) Amount Paid �,-jG�. Payment Date (a VC' <br /> Payment Type Invoice# Check# <br /> 4� Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />