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APPLICANT'S SIGNATUR <br />PROPERTY I BUSINESS OWN <br /> <br />DATE: <br />OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 0 <br />APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />SAN JOAQUPT COUNTY ENVIRONMENTAL HEALT" DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />v <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ...__e tmt-Tre_y/ /7/,/,/,,,,,„ APT <br />SITE ADDig...5_ <br />Street Number Direction Street Name City <br />g. ..<----C) <br />Zip Co <br />(-/ <br />de <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN if LAND USE APPLICATION if <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE <br />PAPA- ON Pcc)/5 <br /># <br />ige,7) <br />EXT. <br />-331/ --2 <br />HOME or MAILING ADDRESS <br />0-.70 __.. I, P LE- <br />FAX # <br />( ) <br />CITY C-- . DO/ <br />S TATEcy,j(_ Zip 93--c, Vc) <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, STAT • FEDE AL laws. <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: <br />-X)4/( <br />COMMENTS: <br />cl• ig lter/ 0 %i) <br />GI4 <br />q <br />MP - <br />it 0,,iii 1,111,4 <br />e 41 t\lk E. 4 Psi- , <br />Th EP ARW EN I <br />ACCEPTED BY: <br />---n <br />EMPLOYEE #: 7_3k, DATE: 37s //al_ <br />ASSIGNED TO: EMPLOYEEi, #: 42,13 DATE: r: . --...-V ,.> /' L.4- <br />Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount: S -0 7134 Amount Paid Payment Date --)/ --)/ <br />Payment Type Invoice # Check # Grl-- / ( ) Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003