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SAN JOAQUIN COUNTY .ENVIRONMENTAL HF..ALTit DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#FAOO �y SERVICE REQUEST# <br /> {-a r C tas matt � O <br /> OWNER/OPERATOR <br /> o/ e r� CHECK If BILLING ADDRESS n i <br /> (� �n e 5 <br /> FACILITY NAME <br /> e/c 1kne 5 Far kyj <br /> SITE ADDRESS J6 D q'? 5. ! t XT A b. �5 c14 LU N 953X0 <br /> Street Number Direction e m i Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) oZ/4/'/y 1 L 'i C K o o k E RD- <br /> Street Number $treot Natne p <br /> CITYG S C F4 L — STA� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (a49) 7,� 78 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (;09) 49 'l - 717k - <br /> CONTRACTOR I SERVICE R_EQUESTOR <br /> REQUESTOR 1 <br /> CHECK If U,l,LLING ADDRESS D <br /> BUSINESS NAME PHONE# EXT, <br /> HOME or MAILING ADDRESS FAX# <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 an&or project specific ENVIRONMENTAL HEALI'ti 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 JOAgUIN <br /> COUN'l Y Ordinance Codes,Stan&irds,STpy and F ta)c ws. <br /> APPLICANT'S SIGNATURE: _ DATE /a V 7 ,2 <br /> PROPERTY/BUSINESS OWNERN OPERATOR i MANAGER ❑ O'rnER AU'rtioRizED AGEN r❑ <br /> If A1'PLIC'ANT is not the BILLIATj P.4RT1',proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environment' i <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL I IF•.AI.TH DFPARTMENT as soon as it is available and at t�A <br /> provided to me or my representative. RECEIVE® <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOAQUIN COU TY <br /> WARONMENTA <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: f* EMPLOYEE#: DATE: t � <br /> ABStGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: ��:j, 1 E: `t <br /> Fee Amount: \�.�. Amount Paid Payment Date Z� <br /> Payment Type Invoice# Check# L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />