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` SAN JOA <br /> 00 COUNTY ENVIRONMENTAL HEALTI-,^'DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C� �s �" ZtO kJ X 7"7 00 S (� ,� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS VAI "k) <br /> Street Numl»r r t et Na it Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �r/Q S S^ w C� A,,-e— <br /> 'STtreet Number Street Name <br /> CITY �A STATE ZIP q©Gb <br /> j <br /> PHONE#1 V V r� EXT. APN# LAND USE�APPLICATION# 0 l LJ <br /> PHONE#2 EXT. BOS DISTRICT _ LOCATION CODE <br /> ( ) <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS IP <br /> BUSINESS NAME �'_. r� � �• PHONE# l� EXT. <br /> HOME or MAILING ADDRESS GG( / FAX# 3 V W�VLOLL4 ? ) <br /> CITY C'� (©�� 0- �t STATE (2f�. ZIP <br /> J J /'a' I` '1 J I��• <br /> BILLING ArKNOWLEDGEMENT: 1, 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 /> 1 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: lu a t,nz. `)t' LC&j4.t,.� DATE: tI 29)q rr <br /> PROPERTY/BUSINESS OWNER[3OPERATOR/MANAGER IJOTHER AUTHORIZED AGENT Cccu t�t�.i ,Q (5'E Ckr <br /> IfAPPLICANT 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. r-� -o <br /> TYPE OF SERVICE REQUESTED: v CN PA p <br /> COMMENTS: C° `, p� Y� <br /> `J�C�IJL� �'�'Q�'��� [D LW xvl� <br /> SAM JOAQNIMENT <br /> .JAN v WEPARTNIEhiT <br /> ACCEPTED BY: j L_ (� t 0-4 EMPLOYEE#: PER 1r:" <br /> �IV� � III �ASSIGNED TO: EMPLOYEE#: � y Z_ ATE: 2 Z/& <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: -3 t Amount Paid , Payment Date ZZ'C) Ci <br /> Payment Type l� Invoice# Check# '3 t Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />