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SAN JOAQ*COUNTY ENVIRONMEN' <br />SERVICE REQ <br />Type of Business or Property <br />FA( <br />OWNER / OPERATOR % <br />FACILITY NAME0161�S� V,n <br />� / <br />1 1 <br />SITE ADDRESS <br />(on <br />Street Number <br />1 <br />Direction <br />Street Nam <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Numbe <br />CITY \v (` , AT <br />n` <br />,aRTMENT <br />PHONE#1 EXT. <br />( l <br />EMPLOYEE #:- j J ATE: <br />APN # <br />PHONE #2 Exr. <br />( ) <br />DATE: <br />CONTRACTOR / SERVIC <br />REQUESTORaLv k <br />BUSINESS NAME C-1 CS S/C -0 / 7%7 7 -7—C <br />HOME Or MAILING ADDRESS (`J /(L S' - A/ r A A) -r A <br />U 7— l / <br />CITY y / 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 atc tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard T E and FEDER <br />AL <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ff OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT • 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: K_ r '1 4 ll�e L 04 L (? <br />COMMENTS: <br />rtkl KV.— <br />I;F `FIVF—nry <br />N®V Q 8 n11 <br />GOON'"ENQ <br />SAN R�MNTAIi. <br />,aRTMENT <br />ACCEPTED BY: E L 1 �.� / <br />EMPLOYEE #:- j J ATE: <br />ASSIGNED TO: tz'` �' t V7 L �y <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: P 2 <br />) L <br />Fee Amount: a _ .,.____ , <br />( <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />