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SAN'JOAQUINUNTY ENVIRONMENTAL HEALTPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#116 A <br /> 5�V 397 <br /> OWNER/QPERATOR <br /> CHECK If BILLING ADDRESSEO <br /> k2C,,Asi �:\u�V C \ s L-C_ <br /> FACILITY NAME <br /> (,o R M Pct 4 Cc- xc= U�tljm2 WAI.,N\A c-A � q <br /> SITE ADDRESSQ C <br /> aa3v w 0E ?ar�3� PCwY Y <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#T ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR QQ <br /> CHECK if BILLING ADDRESS <br /> USINESS NAME1 ! PHONE# EM' <br /> � _ lv�AvEQ C•�znACT \N '�� ( Iib flu-$�S`( <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S 1 p ` 1 k( <br /> l` STATE A ZIP Ck d jg-" - <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 or <br /> 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, STA EDERAL laws. <br /> APPLICANT'S SIGNATURE: ,f1 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT!® V� -c— <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 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. PAYM E N T <br /> pffeEIVED <br /> TYPE OF SERVICE REQUESTED: (,(mss T f'r T <br /> COMMENTS: J U L, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> { <br /> ACCEPTED BY: Ur--( EMPLOYEE#: ©S2 ,f DATE: 7 <br /> ASSIGNED TO: S' I-tf EMPLOYEE#: "13 9-0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 9k P I E: _L, <br /> Fee Amount: ���,�, Amount Paid ��f G Payment Date <br /> Payment Type Li" Invoice# Check# `z �C� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />