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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property n FACILITY ID# S RACE REQUEST <br /> OWNER/OPERATOR L� r�6 V rQ� ( _ CHECK If BILLING AD 1:3 <br /> FACILITY NAME <br /> �eY -FeG 5CJ Gc-►-)C-e � CkJ a� <br /> SITE ADDRESS w _ C� ree LL7C�t, g S Zt D <br /> treet Number Direct tr It <br /> y Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ZZZ g, C L,-,n d b Y- C t-- <br /> tmet Number Street Name <br /> CITY STATE CA ZIP Q Z y <br /> PHONE#') E'R• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y� /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"T' <br /> r I sal r Z AY +S ( 2oc) 3-Z <br /> HOME Or MAILING ADDRESS FAx# <br /> CriGIEr C-( ( ) <br /> ZZ-z Fs <br /> CITY Lv J '• STATE i/ ZIP <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 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: DATE: �Z <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER E30ER AUTHORIZED AGENT E3If APPLICA not the BILLING PARTY,proof of authorization 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 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: S �Ct'7 Qr) L-Ai S l►'1,P S S A <br /> COMMENTS: ,, l Q V-) C v f of I tI�a V F �u,� �c r w�a� SCF Z7, <br /> �V M <br /> Vy '� t In S pec find � cVe two ok N d OS Z <br /> J <br /> �c`avtsS� tiF�<T1/x Q INc <br /> JAcCEPTED BY: EMPLOYEE#: C DATE: 5 l�gRTT NP), <br /> GNED TO: EMPLOYEE#: I DATE: NT <br /> Service Completed (if already completed): SERVICE CODE: O L t PIE: <br /> N 10 3 <br /> Amount: # 15 00 Amount Pai ODPayment DatementTypeT611— Invoice# Check# f 2l D�1DReceiv By: <br /> E 48-02-025 Cow. i# 1 a'4q I O tJ$0 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />