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Circ.5.31-6c11\ STATE ZIP <br />c-i V1/45,2‘)--) <br />REQUESTOR <br />l Fe-A--S <br />CHECK if BILLING ADDRESS 6_t E'sr-=c) <br />BUSINESS NAME PHONE # EXT. <br />HOME or MAILING ADDRESS FAX # <br />t t 0 <br />) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH —PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />;T- <br />FACILITY ID #SERVICE REQUEST # <br />OWNER / OPERATOR <br />S <br />CHECK if <br />--,:?---.-...k. -\_C._ <br />BILLING ADDRESS—.a:A. <br />FACILITY NAME <br /> 0...r _ _•-..._, --..--..,,, 1 (--....1 <br />. SITP A nnrir-- 1 q 2 <br />, „ ,L„ ,,,treet numoer I Direction °LA ki G---o v 1..4_ Street Name (t)-F-0 ,K4c---- City Zip Code <br />gOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(1970q) 9hci— 5-3s--1 <br />APN # <br />o&-e-t--f <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />() <br />BOS DISTRICT 91 LOCATIO? CODE <br />CONTRACTOR / SERVICE REQUESTOR <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property loca d at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the same <br />provided to me or my representative. ----,, z 6 , <br />TYPE OF SERVICE REQUESTED: 7_,E c_ . 14 a4...z.....7-kt 12_,E . A - 1 D40€.-1.-- ? -c•_,) C...)4 E. C-c" SAIN <br />COMMENTS: <br />0 e 6-1' Go(xci, v V 3 c.) pq lido) <br />b y cc) v ekr 4 5 vvl wl er5 ( crt_c.--; <br />POOG- ) <br />k--Aivr'QUIIV ''16_,IL th,ROAiweC <br />e -r-a)* DE-PARAR4: <br />.1._ <br />ACCEPTED BY: 06_ I. ‘..,) e( EMPLOYEE #: OS 21 DATE: 6, <br />ASSIGNED TO: ?,E-o oe_44 EMPLOYEE #: 6 2 (3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5-, -2_ P1 E:3',0 2._ <br />Fee Amount: Ckei.iw'IP Abo t.) 0 Amount Paid \ 0 _____. Payment Date c,1-2 (0 / 0 <br />Payment Type t...------ Invoice # Check # -2- 2- (- Received By: <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)