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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-"'�-Kmo n6nt- SP-0 1GGlq <br /> OWNER/OPERATOR <br /> � ,�IL CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Jr.Gro , �L �j f <br /> Street Number I Direction f " Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> po-c-1 Street Number Street Name <br /> CITY ._b 03 STATE ZIP 9 Q-0-� <br /> PHONE#1 EXT. PN# LAND USE APPLICATION# <br /> (mac( ) G. -�ilI <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> (`).t) ) �.-A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR L-0 <br /> ^��`{ <br /> W ri CHECK If BILLING ADDRESS <br /> BUSINESS NAME \�1'3 PHONE# ^ EXT. <br /> V0 � ��G <br /> t"01 (� <br /> _ HOME Or MAILING ADDRESSFAX# <br /> &t5q q0 �'A-e,1 r-(( Avg . ( ) <br /> CITY (' STATE ZIP I ,� <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,Standards,S:;�7 <br /> 'DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 20 Iq <br /> I <br /> PROPERTY/BUSINESS OWNERSR OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILGING 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: R--) AY+ C Msu l f hon X ^rRE <br /> r <br /> COMMENTS: <br /> AUG 2 g 201 <br /> SAN�pAQUIIV COU <br /> ENVIRpN ZAL <br /> HEALTH pE qR <br /> ACCEPTED BY: Nv\ u e- EMPLOYEE#: �g� ' DATE: 21:1/I 11 <br /> ASSIGNED TO: R M(( 'ef'10() EMPLOYEE#: 3q ,?, DATE: t6 29 <br /> Date Service Completed (if already completed): SERVICE CODE: V' P I E: L4I0 3 <br /> Fee Amount: VS2 Amount Paid Say b CJ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />