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APPLICANT'S SIGNATURE: DATE: <br />SAN JOAQUII, OUNTY ENVIRONMENTAL HEALTH — —PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />3 ,Ai‘ 'IANDEN CHECK if BILLING ADDRESS <br />FACILITY NAME y 4,./Dr1) TisgAptwosy <br />SITE ADDRESS 10 (,) 2... <br />Street Number <br />N <br />Direction SR0A0wAi Street Nam <br />I-Tout-70"i <br />City <br />ciSzo5 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br /> <br />PHONE #1 Err. <br /> <br />5) 'NW — `‘8' ett) <br />APN # <br />pi 2_ - 2-`f 0 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />---riv% Cvz )1Ar CHECK if BILLING ADDRESSEE" <br />BUSINESS NAME A6 vp,AceD ze)EAVI.r0 AP/lc/0-4) <br />PHONE # Err. <br />HOME or MAILING ADDRESS <br />S $ i Arus,) A0A-40 <br />FAX # <br />(7-101) q 10 --) — 1 11g- <br />CITY STATE <br />ST- C 0 CAC 't.b or%) A' <br />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 Codes, Standards, STATE and FEDERAL laws. <br />PROPERTY / BUSINESS OWNER!: OPERATOR / NAGER jEC OTHER AUTHORIZED AGENT 0 <br />If 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 available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003