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SAN JOAQVCOUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of B iness or Property FACILITY ID# SERVICE REQUEST# <br /> C.) <br /> OWNER/OPERATOR l <br /> 1y\ . Lit CHECK If BILLING ADDRESS <br /> FACILITY NAME �/v�0 <br /> SITE ADDRESS <br /> 9;^�2 0 <br /> 17 0 I/lI t Street Number Direction Street Name Zi ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7V Street Number Street Name <br /> CITY rt STATE ZIP <br /> C 5.1 o Y <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> y'6-7) 1 9-7-3 <br /> PHONE#2 EXT. BOS DISTRICT [LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME � // �L // P SNE# � 7 / � EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 7G 8bd 5&X'0-� ( ) <br /> CITY 91; O STATE 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 ENv►RONMENTAL 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: v�-.�_ DATE: / ^.�O —/.3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ff 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 availabPAVTie time it is <br /> provided to me or my representative. RECTI ED <br /> TYPE OF SERVICE REQUESTED: &nSt4ftTL 4 (" SEP 3 0 201^1 <br /> COMMENTS: L r SAN JOAQUIN COUNTY <br /> NP.w VOA) CA i(k 6lil l/1 HEAL H DEPARTMENT <br /> ACCEPTED BY: n CS C�2� EMPLOYEE#: ZZ DATE: 513v I <br /> ASSIGNED TO: &.0 Cs( wo EMPLOYEE#: 1b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E: LA t n <br /> Fee Amount: $.aSD Amount Paid o2S-C> Payment Date 91-30/13 <br /> Payment Type CA4417Invoice# Check# Received By: PA,--i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />