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{ A <br /> SAN JOAQUIIDOUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> FFACIUTY <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-t(/Y�ER/OPERATOR <br /> CHECK If BILLING ADDRESSO <br /> NAME <br /> L I) 4-rG.wtgv- LVli121,5) <br /> SITE ADDRESS <br /> / St�r'eet Number Drlon / GL"� 5?j 7 <br /> Siraet Name CI ZI Code <br /> HOME Dr MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nama <br /> CITY <br /> STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zoq ) 832- Roti <br /> PHONE#2 EXT. <br /> ( <br /> ) BOO DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLINGADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> TGA kWo/v ZOti 36J= <br /> HOME or MAILING ADDRESS Fax# <br /> (077 L C-eGl&/rvL4 1 - 1 -21 <br /> CITY <br /> STATE Cj4 2AP <br /> 9 `JZ�'to <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATEy:P��-//o o% <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENTG ow-r'a <br /> IfAPPLICANT is not the BILGING 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 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. �t <br /> TYPE OF SERVICE REQUESTED: C( S7- ,FfT <br /> COMMENTS: A <br /> CEI VED <br /> FF8 2 2 2006 <br /> SAN EN JOAQUIN COON <br /> ACCEPTED BY: HEALTH ONMENTAL <br /> DATE: TY <br /> G c i L� /�!� EMPLOYEE#: �)S 2 <br /> / Z 2"7�U � <br /> ASSIGNED TO: h' EMPLOYEE#: �,-�5.> DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: (� P/E: <br /> Fee Amount: `4 2�7�. i,v Amount Paid 1 Payment Date y'1 �b <br /> Payment Type L-�- Invoice# Check# Received By: �- <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />