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SAN JOAQL 7OUNTY ENVIRONMENTAL HEALT. EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR &�Oy�k <br /> G CHECK if BILLING ADDRESS <br /> FACILITY NAME -.� '1 u— <br /> _-SITE ADDRESS rb /1 <br /> 1 Street Number Directioneet Nal(m`)e—E��, city [/ Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number F Street <br /> AECEIVED <br /> CITY ry t—� STATE ZIP <br /> PHONE#1 EXT. APN# lQ.l G►O1� l�� LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT ° J. <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME / EXT. <br /> CC\U�`V` PHO'E# <br /> HOME or MAILING ADDRESS FAX# <br /> 2gu 0 10 - 15an •L O �\vc�. ( 1 <br /> CITY STATE Uc� ZIP 1743 I (� <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, STATEIcind FEDERAL laws. <br /> APPLICANT'S SIGNATURE-: DATE: �'�-r 11, a l5 <br /> PROPERTY/BUSINESS OWNER[% OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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 environmentaUsite 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��mee``orr my representative. --�^ <br /> TPIAVMP QUESTED: � Yz U �L�?`'�-1<_✓`� �1 �Tm .L I1h <br /> DEC <br /> AN JOAQUIN COUNTY <br /> ENVIROME.NTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C-;2 � <br /> rz� EMPLOYEE M DATE: o/�_ ;) l <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: // P I E://` �1 a <br /> Fee Amount: 0 1 Amount Pai1.� UD Payment Date <br /> • /L/J� GDIJ <br /> Payment Type Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />