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- ELT DEPARTMENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTft DEPARTMENT <br /> SERVICE REQUEST <br /> RNAME <br /> Business or Property FACILITY ID# �-� , SERVICE REQUEST# <br /> 1 L-F—✓ ��(� I—AC I L.LT_y <br /> /OPERATOR SEAN AQ)U) r10 CHECK H&WN,::A tD SS <br /> AME M RESSStreet c AILING ADDRESS (If Different from Site Address) Street Namet�rtvT� STATE Zip 3ET. APN# LAND USE APPLICATION# <br /> �L({Q- S�� <br /> PHoNE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If&WNG ADortE55 <br /> BUSINESS NAME PHONE# E'' <br /> HOME Or MAILING ADDRESS FAX# <br /> CIT STATE ZTP <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TATE a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1�" I– W <br /> Ol/ <br /> PROPERTY t BUSINESS OWNER OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1fAPPLICANTisofthe6HZI"GP,IRY <br /> proof ofauthorizadon 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 environmentaVsite 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: I Citi <br /> COMMENTS: <br /> ACCEPTED BY: �. EMPLOYEE#: �J t DATE: 7 <br /> ASSIGNED TO: 1 - Z3 <br /> EMPLOYEE#: I%/�'Cl DATE: <br /> 0 23 C� <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> PIE: / 0 <br /> Fee Amount <br /> L � Amount Paid Payment Date <br /> Payment Type ; Invoice# Check# <br /> / Ch Received By: <br /> EHD 48-02-025 �lL "`� -- l f-fliY(&q' <br /> REVISED 11/17/2003 _(_I l'"� SR FORM (Golden Rn i� <br />