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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST p P-01K'909 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00ouegi R(166011 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NA i5 <br /> SITE ADDRESS WI'J J <br /> 0''1 W <br /> L 1 ( St et umbar Olrec lon S r1at Name �\ CI �IUCJode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) _ <br /> r ixy' G Street Number (�O.t-�tl. Strae ma <br /> CITY _Q STATE ZIZ, 1 <br /> L \ '-1 <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> (UR ) - Z <br /> PHONIER d(ra 1 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) lA Gr ao • Co <br /> C TRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE]I L,�^—I q 74 � 1" <br /> HOME or MAILING ADDRESS FAX# 1 "`C <br /> ( ) <br /> CITY STATE 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,Standar , TATE andFEps aws. <br /> APPLICANT'S SIGNATURE: DATE: 10-5--d <br /> PROPERTY/BUSINESS OWNE OPERATO /MANAGER d OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLINGPARTT 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. PA <br /> TYPE OF SERVICE REQUESTED: t RECE <br /> COMMENTS: <br /> h � ("�)��oo co � OCT o s zo2i <br /> .e noAYu s ISAN <br /> JOAQUIN CO <br /> p�UNTYHETM DEW <br /> ACCEPTED BY: /J EMPLOYEE#: r1t DATE: p <br /> a Z/ <br /> ASSIGNED TO: Ilez141 <br /> EMPLOYEE#: :53 / DATE: <br /> Date Service Completed (if already ompleted): SERVICE CODE: Q 1'11E:E: <br /> Fee Amount: �' Amount Paid (5 a! Payment Date I p <br /> Payment Type Invoice# Check# �v� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ?901ubuLOLI <br />