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SAN JOAQL.-.. COUNTY ENVIRONMENTAL HEALT_ DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FA ILITY ID# � <br /> SERVICE REQUEST# s <br /> g fz. <br /> OWNER/OPEIR�ATOR <br /> leJ� MIL-Len CHECK If BILLING A00RE55� <br /> FACILITY NAME Va L-A7V P �"� t L CD V'11'C VI\/ `L <br /> SITE ADDRESS 14 G Z j L� D? t,L La K tL �- [- <br /> Street Number Direction Street Name CII Zi Cotle <br /> HOME or MAILING <br /> r ADDRESS <br /> A(If Different from Site Address) t' <br /> 2So� V• - yr2 L—�Y+ ✓1/l� 9Q.,Number Street Name <br /> / CITY,�GILTO/J S0-. LPq�U� <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (2LAj 3q-R8-L(8 0 1lll <br /> PHONE#2 EXr. BOS DISTRICT b LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Er' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 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 Codecs Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGN..Fl7RE: lJ" DATE: , <br /> G/� LI <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PAR TP 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 <br /> TYPE OF SERVICE REQUESTED: V+�f�_�� CEIVE . <br /> COMMENTS: / t L ( 1.k L C� I Z,'b r p17 204 <br /> L SAN JOAQUIN COU <br /> NTY <br /> ENWROMENTAL <br /> HEALTH DEPARTMEA IT <br /> ACCEPTED BY: 1 t �r" EMPLOYEE#: DATE: f (4- <br /> ASSIGNED TO: .lam t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: L/GQ-r <br /> Fee Amount: L -3;D Amount Paidfl)30. b D I <br /> Payment Date <br /> Payment Type ✓ Invoice# Check# 13�g 'Rec�ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 - <br />