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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �oo6 sgo02y <br /> OWNER I OPERATOR 4 <br /> CHECK R BILLING ADDRESS <br /> FACILITY NAME � �n 'S <br /> SITE ADDRESS `'1 1'l S -1601 (]�f1 S-� �� a ai20(,i <br /> SIR 131r tNa e <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2J S+ <br /> t Name <br /> CITY 1 I ^ STATE CA YIP <br /> PHONE#11 ExT• APN# LAND USE APPLICATION# <br /> G� 1 _JgC <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C1 f_e <br /> n I` CHECK if ]LLING ADDRESS <br /> BUSINESS NAME PHONE# Err' <br /> HOME Or MAILING ADDRESS / I FAX# <br /> CITY STATE CA ZIP <br /> BILLING ACKNOWLEMEMYNT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvmoNmENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or Day 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 JoAQunv <br /> CouNTY Ordinance Codes,.Standards,STATFAnd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - DATE: 02 ! <br /> PROPERTY/Busvass OWNER)I OPE TOR/MANAGER © OTHER AUTHORIZED AGENT O <br /> IfAPPL1cANT is not the BILLINGP.4R7Y proof of authorization to sign is required Trate <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 JoAQu N CouNTY EwiRoNMErrTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. AbA. <br /> TYPE OF SERVICE REQUESTED: u 0 LV/*? /.� •q <br /> COMMENTS: FFB �D <br /> CA,WI 1 �Fp FM' HAY <br /> ACCEPTED BY: c EMPLOYEE#: �) DATE: ! n <br /> ASSIGNED TO: W�go G J EMPLOYEE#; V+ DAA: I 1 nG <br /> Date Service Completed (If already completed): ERACE CODE: 1 P 1 E: 1 C/6/3 <br /> Fee Amount: [(::—�)2-60 Amount Paid Payment Date 16, <br /> Payment Type Invoice# Check# 42072Y-703 Racelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />