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iJANJ©YIQUINiUNTY'L+iVVIRONMEN'FAI't1EALT11'�;I'ARTMENT <br />SERVICE REQUEST <br />Type'' of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OCT 1 12004 <br />PHONE If Ezr. <br />HOME Or MAILING ADDRESS <br />IV i'Ekt.rt- .J <br />FAX# <br />CITY <br />OWNER OPERATO //� I,t <br />l /J <br />CHECK if BILLING ADDRESS� <br />ES' NGcC-e'l <br />C�%S lo-� <br />ACCEPTED BY: L t V z I <br />FACILITY NAME (t,/L%� !"jam <br />�j p�t+G-vim <br />�, c� Z_ I <br />SITE AD RES! —art—'•'w_��� <br />ASSIGNED TO: L <br />EMPLOYEE #: <br />� � <br />DATE: IG 11161 <br />61 Nu ber Direction <br />`� Street Name <br />PIE:3 <br />Fee Amount: x-19. G t, <br />i Code / <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Payment Date <br />Payment Type �. <br />Street Number <br />Check # <br />Street Name <br />CITY <br />STATE Zip <br />PHONE#tZT <br />APN # <br />LAND USE APPLICATION # <br />t � ) ✓ �� vD 7 <br />PHONE #2 ET. <br />t ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />`1 <br />CHECK If BILLING ADDRESSD <br />BUSINESS NAME <br />OCT 1 12004 <br />PHONE If Ezr. <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY <br />STATE Zip <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 HEALTit DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this fomL <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, a d FEDERAL la s, <br />X APPLICANT'S SIGNATURE: - DATE: /C/l`a / � Y <br />PROPERTY/ BUSINESS OWNERN OPERATOR/ MANAGER ❑ OTHER AUTHORIzED AGENT <br />YAPPL/CtNT is not the BtLLtrvG 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 environmentaVsite 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: (�( _ST �� 71-0 I T <br />RECENS <br />COMMENTS:' <br />OCT 1 12004 <br />SAN JOAOL�NVIROUIN C OLj Ty <br />ENTAL <br />NEq T H OE AR <br />CNI- <br />ACCEPTED BY: L t V z I <br />EMPLOYEE #: <br />�, c� Z_ I <br />DATE: IC, bf G r <br />ASSIGNED TO: L <br />EMPLOYEE #: <br />i S,4 -U <br />DATE: IG 11161 <br />Date Service Completed (if already completed): <br />SERVICE CODE: % �� <br />PIE:3 <br />Fee Amount: x-19. G t, <br />Amount Paid .. <br />Payment Date <br />Payment Type �. <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />