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SAN JOAQUIN C ';Ty ENVIRONMENTAL HEALTH I*kRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR rt O/^/i , //C` / <br /> Q(A 5 HECK If BILLING ADDRESS O <br /> LLL G]�GG] <br /> FACILITY NAME <br /> SITEADDRESS 23!33 <br /> Street Number I Dirwection Street Name J I LiF_ Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Si_e�IAddress) <br /> 7 r Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) 472 - ZZSD <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I� <br /> _ CHECK If BILLING ADDRESS <br /> BUSINESS NAM / PHONE# Exr' <br /> tea pE2 ( ? <br /> HOME Or LING ADDR�SS 99 <br /> CITY �V, /Q // STATE P <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 bourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on this foral. <br /> I also certify that I have prepared this appl ion and that the work o e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, !AT and FE RAL law . ` (D <br /> APPLICANT'S SIGNATURE: DATE: ( ` 2,7 - U / <br /> PROPERTY/BUSINESS OWNER 11 OPERAT /N'IANAGER ❑ .OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTisnotthe BILLI G PARTY proof of authorization to siglr is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> J 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: �O[— YOnn <br /> L1+nJ Cf-I I-C/L RECEIVED <br /> COMMENTS: JAN Q 7 20C4 <br /> SAN JOA- I !."!tf <br /> ENVI <br /> HEALTH <br /> ACCEPTED BY: OL—t U £ I P2,+ <br /> EMPLOYEE#: 2-7 O3 DATE: u <br /> ASSIGNED TO: COLD '0 €/lS—_A EMPLOYEE#: 0[F& DATE: <br /> Date Service Completed (if already completed): SERVICECODE: j"23 PIE: 3G•O� <br /> Fee Amount: Amount Paid�'�.a — Payment Date IA? I 6 <br /> Payment Type Invoice# Check# /a Received By: // <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />