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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />t5 C.),..)A—r&c---" t5 of 'Ni <br />CHECK if BILLING ADDRESS OWNERL 11)0 PERATOR <br />FACILITY NAME <br /> 11/74 &- <br />SIScimber Direction <br />SITE ADDRESS ro <br />/1114114443a Name at- City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. I <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE ;2 EXT. <br />i <br />1 BOS D:c-no-r <br />I <br />II 1 oce-nnti enDF <br />ll <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br /> <br />P4/0) <br />BUSINESS N A , <br />PG•fS-7-- <br />Cirr <br />HOME or IVIAILiNG tre <br />Y' 9' rie.0477--A-6 <br />STATE <br />CHECK if if BILLING ADDRESS': <br />PHONE # EXT. <br />5 F9 3'3/7 <br />FAx# <br />( <br />z9 3-36re <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 FEDEKAL I ws. <br />APPLICANT'S SIGNATURE DATE: •-• —0 <br />PROPERTY / BUSINESS OWNEREI PERATOR / MANAGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is 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: 1 )c 44 i i+) (--onLk,y- <br />COMMENTS: <br />7 i <br />/ <br />HAY IVI EN I <br />RECEIVED <br />APR 1 9 2005 <br />SAN JOAQUIN COUNTY <br />Ervipni\IMPNTAI <br />Falt:THCEPARTM ENT. <br />1-151-0 ACCEPTED BY:)c <br />Z- -2-' L------' -.--' ------&--- EMPLOYEE #: qpii_49 <br />ASSIGNED TO: PI oil r k, EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: <br />C (C i <br />P/ E: <br />Fee Amount: *1.3 ,60 Amount Paid litifi .7(c) S--- Payment Date <br />Payment Type Type Invoice # Check # i .12 uf ,,33) Received By: 4. 1 <br />f <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003