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SAN JOAQ10 COUNTY ENVIRONMENTAL HEALTIVEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR fcIA17) <br /> .eeiUlk CHECK If BILLING ADDRESSFACILITY NAME �C �lll�///�,l, <br /> SITE ADDRESSS <br /> /►/► 64 G F2—07 <br /> 1206 Street Number coon '`/i Street Name Cp Cit Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number Cor te" ` C Street Name <br /> CITY STATEZIP 6 J l <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# l <br /> ('�ln ) W7-751,t <br /> Q/ <br /> Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR femme- l1 P CHECK If BILLING ADDRESS <br /> BUSINESS NAME P PH5-`0# .- 7? EXT. <br /> HOME or MAILING ADDRESS V C FAX# <br /> (nr� v ( )-07 ) 767---6gg3 t <br /> CITY FYI DY) I STATE C �L}- zip gLi53 1 <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 FEDE��L laws. <br /> l ' <br /> APPLICANT'S SIGNATURE: DATE: /�[[J /� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILaNGPARTY,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. <br /> TYPE OF SERVICE REQUESTED: G�S Ltfj?diti� "� — L.�G - c a lrlirl�i� r <br /> COMMENTS: RECE!p si=n <br /> JAN 2 6 i <br /> SAN JOAQUIN COUN <br /> ENVIROME TA <br /> ACCEPTED BY: EMPLOYEE#: / L DATE: Z S EN <br /> ASSIGNED TO: Cdr c�s EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: (F; f P/E: _2-3[f <br /> Fee Amount: 2— "' C% Amount Paid Payment Date J 2�//3 <br /> Payment Type Invoice# Check# Received By: I ; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />