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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> VCVSDN l zzm2m <br /> OWNER/OPERATOR-7 <br /> ^,��CA C �C A CHECK if BILLING ADDRESS E] <br /> Com <br /> FACILITY NAME ` c �G `atom` C <br /> SITE ADDRESS `I /t <br /> Number Direction I'6V� Street Nam Cit' Zi CO � <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> I (� l� Street Number Street Name <br /> CITY C* STATE zip Ci52[3 <br /> PHONE#f E-, APN# LAND USE APPLICATION# 1 <br /> PHONE#2 EXT. BOS DISTRICT11 OCATION CODE <br /> L <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TQ,�� 6're' '^ <br /> ' l 5{n �•,(� Vi 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME � PHONE# EXT. <br /> P►nv. two( NCL Spud i� 5 ^D 1 <br /> HOME or MAILING ADDRESS FAx# <br /> CITY ! STATE zip <br /> ` J� 1 <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, TATE and FE w <br /> F <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERLAV OPERATO /MANAGER [3OTHER AUTHORIZED AGENT❑ <br /> If APPLICAN LS not the BILGING 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. AbA. <br /> �+ <br /> TYPE OF SERVICE REQUESTED: �t7 �j0pp 411 <br /> COMMENTS: VP111 <br /> sero✓��i X019 <br /> FNVI gQ�tN C <br /> H�tTy p MRCT CN7Y <br /> ACCEPTED BY: JEAST - EMPLOYEE#: 98 Z Z DATE: t�. 9 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: I 2 <br /> D - <br /> Fee Amount: �SZ Amount Paid 5;Z, D p Payment Date ".. 1-7 !I <br /> I Payment Type Invoice# Check# Received By: <br /> L� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />