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• SAN JOAQUOOLNTY ENVIRONMENTAL HEALTH&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ---] FACILITY 10# SERVICE REQUEST <br /> F-0 (�—N7 �50 i C SS A Q�0 a-11- L�v CV Ly 1-7—/Z/p� <br /> OWNER/OPERATOR CHECK if BILLING AOORESS fJ <br /> FACILITY NAME JeT�p <br /> SITE ADDRESS �2 f� �.-�1 it� 1 kl —I <br /> street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#t a EXT. APN# LAND USE APPLICATION# <br /> -7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR1 ,_ n 1 CHECK if BILLING ADDRESS Y <br /> BUSINESS NAME lN!'RI `l+ ` PHONE# EXT. <br /> Lei 3b7 37d t <br /> ROME or MAILING ADDRESS FAX# 30 ZZ <br /> CITY Lo'I STATE F A Zip 752-t16 <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: j + ' Vey DATE:_ '6q 6i2 Q s <br /> PROPERTY/BcsINESS OWNER[I OPERATOR/NIANAGER OTHER Au'rHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING P,4R7Y,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 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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: L( J RECEIVED <br /> COMMENTS'. <br /> APR 4 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: M OYEE#: q17 C/Jr DATE: <br /> ASSIGNED To. EMPLOYEE#: i V \ PATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O L <br /> Fee Amount: Amount Paid 2 71/-,p- Payment Date i Q ` <br /> Payment Type �/ Invoice# Check# 7Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117122003 <br />