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*r i ,, AN 4.04 N COUNTYLNVIRONNIENTAL-IIFAl'II=UEI'AR'I'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSE] <br /> FACILITY NAME . <br /> �-'�c �lCt 7` �r iq � �c C'a v �r � ��►�s �'('�' ST9-�i�'�-r <br /> SITE ADDRESS17-5-3 <br /> C} Gr 3 <br /> Street Number Direction Street Name C Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1T APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /�/�l�� JLfer T��'r�t / �' CGL/�/y 5� PHONE# T <br /> HOME or MAILING ADDRESS FAX# <br /> �s (ZO ) '93 2- <br /> CITY �I. C ?5-3 16 STATE C- 4 ZIP 17.5-3 .fes <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 or <br /> 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 /> APPLICANT'S SIGNATURE. DATE: //2 5 <br /> PROPERTY/BUSINESS OwNERQ OPERATOR(Ml— ❑ OTHER AUTHORIZED AGENT❑ ftQCic <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTIIORIZATI.ON 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: it -7— 7 %_ <br /> COMMENTS: p C H rr►Gs�l� !>z✓i ytyt /�/p'��tf ���y� <br /> 'ZD vn - iD•oc"Z c�c t w�cw E��R Tt- <br /> ACCEPTED BY: C EMPLOYEE#: ! DATE: <br /> ASSIGNED TO: Oy G� © EMPLOYEE#: 110-40 4 DATE: �� I <br /> Date Service Completed (if already complet d): SERVICE CODE: Z� P i v Z <br /> Fee Amount. 196 Amount Paid Payment Date <br /> Payment TWO Invoice# Check# Received By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />