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SAN JOAQU%,:OUNTY ENVIRONMENTAL HEALTI*,80e:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bpe, ca I 19 -7 Sf2 b 5&931? <br /> OWNER/OPERATOR n^ 1 <br /> &Mp<ec � 3�4 ' CHECK If BILLING ADDRESS <br /> FACILITY NAME 1-/a <br /> $R ADDRESS � um A /1_a nO L\ t !U ([- x.I Qciw f . qs I O <br /> 1 � Street Number Direction 1'e UPC1L-L71'1 SL[•reet�Na�meKJ LL��CL'��-1' -1 i7ZCi�Code <br /> HOME or MAILING ADDRESS (If Dj(ferent from Site Address) �t/t 1 j2CA'o <br /> J-475Lr l� Street Number JT`-f �-U treat Nam <br /> CITY VV�_/�c- �w1/ /r.STATE A ZIP gL4�9 <br /> PHONE#1��� ExT APN# LAND USE AAPPPLICA70N# <br /> 12CA )gSLt ' CABS <br /> PHONE V Ea. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR tM t1,•1'+ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex. <br /> rin)[OES , Sim <br /> HOME or MAILING ADDRESS FAX <br /> Po. C;bcO-1t IR i11 <br /> CITY�v STATEQA ZIP Cmcc-2-0 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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: '_l /[7 1Y�,NW DATE: <br /> 1 <br /> PROPERTY/BUSINESS OWNER❑ LTIPERATOR�GER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BILLING PARTY proof Of authorization t0 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a i is.available and at the same time it is <br /> provided to me or my representative. D t� <br /> TYPE OF SERVICE REQUESTED: IV <br /> COMMENTS: ('� N ' 4 2pp9 <br /> f`}l' tn3'�' I 2 <br /> -P 34-5' 1�' � �� � ��` ENVIRONMENT ROO � <br /> 000 <br /> 3 4 S �`" Il7 F� P erg; ('ERMIT�SERV� ;SoP oNME�Mti <br /> ENSIHDEPP� <br /> Nom' <br /> ACCEPTED Y: EMPLOYEE#: DATE: Z <br /> ASSIGNED Tor"�V'eff EMPLOYEE#: DATE7 77 <br /> : y <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:Z3 D Q <br /> Fee Amount: 3`1`5 ° Amount Paid Payment Date �� '1,,k L Q <br /> Payment Type Invoice# Check# a 5 O Received By: "75- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />