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SAN JOAQUIP' `aOUNTY ENVIRONMENTAL HEALTY'IEPARTMENT <br /> SERVICE REQUEST ` <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c � f�`/ 12QOJai96 <br /> OVINEV OPERATOR ( <br /> S <br /> �`� �a1\�♦\ QY� G�;C ��` CHECK It BILLING ADDRES <br /> l `^ <br /> FACILITY NAME <br /> SITEADDRESS 265 511 I'1\f' � �tV SWI <br /> Street Number Direction 1 Street Names Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> snw%q_— Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# <br /> GM- 255 07 /2003/ %V'1 LAND USE APPLICATION# <br /> (2Qg) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR P (Zf'O We tJ� <br /> •PS� �`�^ CHECK if BILLING ADDRESS <br /> BUSINESS NAME \ �Y yy F�f Exr. <br /> GW\ -0011 Pxb�D# 0 G" (3,%Z3 <br /> HOME or MAILING ADDRESS FAX <br /> 2\0 WQ� �a.. .�� has ( �) Z�\ <br /> CITY I� Q`VM�a STATE ,KL- zip 'ZZ3eo <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorize 4getil <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associaRILP _ r <br /> 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: p�i-tom DATE: t' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 9 1;V <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 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. PAYM ENT <br /> TYPE OF SERVICE REQUESTED: u 5 f <br /> COMMENTS: OCT <br /> SAENOAQUIN COUNTY <br /> VIRONMENTAL <br /> U �� PAHTMENT <br /> R I <br /> ACCEPTED BY: EMPLOYEE#: Y6 YY DATE: s Q <br /> ASSIGNED TO: I EMPLOYEE#: 3 / DATE: <br /> Date Service Compl d (if already completed): SERVICE CODE: PIE: 2 d d <br /> Fee Amount: L11 Amount Paid 't LF L1 C-L) I Payment Date <br /> Payment Type S Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />