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V -1c <br /> SAN.TOA( v T COUNTY EiVVIRONMEl�1TAL HEALTEP <br /> SERVICE REQUEST ![+ II✓/ <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> vc <br /> 17i <br /> OWNER/OPERATOR T ;,` 1,,, <br /> Q� W, I � kA1001 CHECK If BILLING ADDRESS E] <br /> FACILITY NAME r ' -'ILA �A( J <br /> SITE ADDRESS 1. L � J <br /> C <br /> 73 �f 4I <br /> Street Number I Direction Street Name Ci j Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) c� A �r + <br /> b� <br /> reet Number Street Name <br /> CITY y�_ STATE (IIA Zip <br /> IV11"►1 I J l' <br /> PHQNE 1 APN#l ^ €x7. <br /> (Q J f{y) LAND USE APPLICATION# <br /> � u � <br /> 92 <br /> a eCp?` Ems' BOS DISTRICT LOCATION CO <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE:STgR ,�1 Y , <br /> CHECK if BILLING ADDRESS <br /> i 77vv +V <br /> BUSINESS NAME PHO E €xT. <br /> HOME or MAILING ADDRESS S, QQ 2-- '756' <br /> � K ( � 7) / <br /> CITY 1 n -0 STATE 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 thilicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COt'NTY Ordinance Codes,Standards, STAT and DE L s.' � <br /> APPLICANT'S SIGNATLIRE: DATE:— <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER OTHER AUTHORIZED AGrNT❑ <br /> ffAPPLICANT 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,mvjranmentalfsij 'assessment <br /> InfO-Imaticsl to the SAKI JOAQuTN COiRgi't-ENVIRONMENTAL liEALTH DEPARFMILIN i as soon as It is aval3 One it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L MAR <br /> t��/t!t� r� <br /> COMMENTS: NGV4R,0�42, <br /> Irl11i7CAM <br /> �Q0(/ UtyD pM v- 7Y <br /> �RrMF�'T <br /> ACCEPTED BY: t/ EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: J <br /> Fee Amount: Amount Paid � CU <br /> Payment Date 1 c <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />