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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �(C- - ,- A <br /> .7 - 5603 -) 0q 7 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILfTY NAMEn �^ ,�` L <br /> SITE ADDRESS - A A C-<{ <br /> leet Number Direction .J .P Beet N me Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#i ExT. APN# LAND USE APPLICATION# <br /> ( dry 4q . 1� I � . <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4/1/�44 �r� CHECK if BILLING ADDRESS E]- I <br /> BUSINESS NAME _ PHONE# a ExT. <br /> ,J l.v�A%.>C 2 C o �T �. A c.-r � . <br /> HOME Or MAILING ADDRESS / FAX# <br /> l <br /> CITY I Y 1�l STATE CA ZIP <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,STATE DE S. j <br /> APPLICANT'S SIGNATURE: - i DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT — <br /> IjAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: �{.S'T jc� F C I <br /> PAYMENT <br /> COMMENTS: RECEIVED <br /> APR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: /`�� ��' EMPLOYEE#: 3 u DATE: <br /> ASSIGNED TO: Sv,rl EMPLOYEE#: --7 3 M DATE: �T /S <br /> Date Service Completed (if already completed): SERVICE CODE: / P i E: A-?_p 8 <br /> Fee Amount: %�7c/"to 1. Amount Paid I Payment Date <br /> Payment Type ✓ Invoice# Check# / 7 9 Received B . M.,1 , <br /> EHD 48-02-025 <br /> SR FORM(Golden Roel <br /> owiccn 111471-n01 <br />