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NCS�ICL 2_ of <br /> SAN J,TQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 957 5t«v .sag 9� <br /> OWNER/OPERATOR <br /> � CHECK 1f BILLING ADDRESS <br /> FAClL1TY NAME - ' - - ` - - <br /> �/�, ( , <br /> SIT1=ADrJR£SS �G� -l_-' <br /> Street Number Direction Sheet NameCi 2i Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) . <br /> Street Number Street Nano <br /> CrrY STATE: <br /> PHONE#I - APN# LAND USE APPLICATI <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> { l <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> REQUESTOR <br /> CHECK i f BRLING ADDRESS <br /> BUSINESM <br /> S NAE PHONE ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE CA <br /> ZIP Q <br /> 1 <br /> 5 W5 <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 ENvrRoNwNTAL 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 SIGNA.TLTRE:_ pJ'� �%oG DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER 0 OTHER A uTHOR17XD AGENTS] <br /> IfAPPLIC4NT is not the BILLINGPA_'RTY,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 avaijable and at the same time it is <br /> provided to me or my representative. HAYMEN <br /> r <br /> rOMMTYPE OF SERVICE REQUESTED: .N75: �. VED <br /> ��� <br /> E <br /> �► gaUrNr <br /> " cOU <br /> R U df x. H d PARTTMENT <br /> IVT <br /> ACCEPTED BY: EMPLOYEE#: V DATE: /7 <br /> ASSIGNED To: n l ; �,� � EMPLOYEE#: DATE: 14•x, U <br /> Date Service Completed[ (if already com e SERVICE CODE: lPc!E:Z <br /> Fee Amount: r .U� — Dunt paid Payment Date <br /> i1I" 34S. vb y 1 31 p <br /> Payment Type ✓ invoice# Check# l 1f 7 I C?? Received By: <br /> EHD 48-D2-025 .: r,L <br /> REVISED 11/17/2003 � SR FORK(Golden Rad) <br />