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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RC'�):h1JM111 I F� b b v 14 Og I SRQZ�6-Vil-� <br /> OWNER I OPERATORd2- '1 � CHECK if BILLING ADDRESS❑ <br /> FAmn NAME _5 <br /> �1�� � C' <br /> SITE ADDRESS q l �/r7 rn 1_ � �11 YLkt-c'� c(5 3:36. <br /> Street Number tion Name CI e ' <br /> DOME or MAILMIG ADORES% (If Different from Site Address) <br /> Street Number SVW Name <br /> CITY STATE ZIP <br /> PHONESI Eur. APN# LAND USE APPLICATION <br /> (ZDV{) Z.ZS <br /> PHONE Eur. BOS DISTRICT LOCATION CODE <br /> r Z75 � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ! y l le 2--., CHECK if BILLING ADDRESS <br /> BusiNEss NAME rte/) PHONE/ EXT, <br /> b' CA <br /> HOME or MAILING ADORES FAX# <br /> C07 E. D r <br /> CITY 1 l STATE LP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL'ni DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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: �b1(01 44WW,1 C' -ZJ DATE: © Z - Z L Z Cf <br /> PROPERTY/BUSINESS Ow\ER1 OPERATOR/MANAGER O OTHER AtrrHORI7sm AGENT 0 <br /> !fAPPLICAAT is not the BILLING PARTY,proof of authorfzadon 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI 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: <br /> COMMENTS: <br /> ACCEPTED BY: t EMPLOYEE#: DATE: 2 q Z <br /> ASSIGNED TO: T EMPLOYEE#: DATE: <br /> Date Service Comple (if already completed): SERVICE CODE: O P i E: 6 <br /> Fee Amount: L Amount Paid I lXae� Payment Date <br /> Payment Type InvoiceOL # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �R �I � 01 � <br />