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SAN JOAQUIIOUNTY ENVIRONMENTAL HEALTI"EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SIC �hcc��� <br /> 'DCO )h 17< wst q <br /> OWNER/OPERATOR <br /> -•��C� CHECK if BILLING ADDRESS <br /> FACILITY NAME I-e V t%\:k S k,4n ca <br /> SITE ADDRESS c� V\ 1 . ,_ CC J FJ/—DC q�Z o3 <br /> Li Z3 L�t -n Street umber Direction V J 1 Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Narne <br /> CITY STATE ZIP <br /> PHONE#11E-, APN# LAND USE APPLICATION# <br /> (?Otv � S Z - 2 Zq °I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � �y�_ <br /> �� CHECK 1}BILLING ADDRESS <br /> BUSINESS NAME l:J I$��C� S K/6 1�"(��4- Gj PHONE te# r� � �,c1 <br /> HOME or MAILING ADDRESS 1� , '�„�1 � I nY FAX# <br /> CITY S �Orr STATE / /a ZIP c7 2,J7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F KE/Ry�AL laws. <br /> APPLICANT'S SIGNATURE: �G% u''�/ow)v-- DATE: <br /> PROPERTY/BUSINESS OWNEI$ 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, 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 JoAQufN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and Aa-me time it is <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: OE)rs 'v <br /> COMMENTS: do <br /> S S <br /> ti "Qui ?�19 <br /> Ty�FAgRhT COU, <br /> MFHT <br /> ACCEPTED BY: M �i l EMPLOYEE#: DATE: •(O� <br /> ASSIGNED TO: S /� OV EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( P/E: �Q <br /> Fee Amount: 01 2— Amount P Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />