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11 <br /> 12 22, 12:58p P.1 <br /> i■ <br /> ■: <br /> it <br /> ■ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE Ra T# <br /> N CD 0c) SRao8 Z , f <br /> OWNER I OPERATOR <br /> ® / CHECK If BILLING ADDRESS <br /> a KP GO LJCa <br /> FACIUTT NAME G \ � i <br /> SITE ADDRESS `oa: ��5c� er 7-ro\c a Z'3 \0 <br /> Street Number Direc[lon Street Name C zip Code <br /> HOME Or MAILING DRESS (If Differ t from Site Address) <br /> J o Street Number SUve(Namo <br /> IN <br /> � CSTATE ZIP <br /> G� Q 30 <br /> PHONE#1 E`T' APN LAND USE APPLICATION# <br /> PHONE 2 E%r. BOS DISTRICT LOCATION CODE <br /> o j5VL <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ' <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 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: <br /> PROPERTY/BUSLNFSS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPUCANT is not the B/LL1NG PAR proof of authorization to sign is required ru[e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr-.party located at the <br /> -above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenta lsite 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: n <br /> COMMENTS: REPA/1EIEAIT <br /> li VVE p <br /> AUG 301011 <br /> SAF 'AQUI <br /> 6l CO3 <br /> bil <br /> ACCEPTED BY: EMPLOYEE#: - �H DEoAENrAL <br /> ASSIGNED TO- EMPLOYEE#: DAA: <br /> Date Service Completed (if already completed): SERJNCECODE: PIE: 1 02 <br /> Fee Amount: x ;5 �-s � I Amount Pa' ��� OZ) Payment Date g ;22 - <br /> Payment Type V i -5IL� Invoice# \,Check# ��' 1S$ S� Received By-. <br /> EHD 48-02-025 {�U��C.L(l('�� \n , `�f�S SR FORM(Golden Rod) <br /> REVISED 11/17/2003 201� _ Ij �niD <br />