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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI+11FIEPAR'I'MENT <br />\/ SERVICE REQUEST .,/ <br />Type of Business or Property <br />FACILITY ID # <br />P AYM <br />SERVICE REQUEST # <br />. (� <br />BUSINESS NAME <br />5ea0 <3-2 913 <br />OWNER/ OPERATOR <br />En. <br />T <br />L <br />IO <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />FAX# <br />SITE ADDRESS /3ZtPpSQ-�Ou[.L'CJC..�L"_ <br />ZO <br />!-L_ T— <br />1 (Z ) <br />tLDI\ <br />9 .SZQS <br />Street Number <br />Direction <br />Check # 'a ' <br />Street Name <br />ceived By: <br />Cll <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 E.- <br />APN It <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />P AYM <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />EMPLOYEE#: Q3� <br />PHONE# <br />En. <br />T <br />EMPLOYEE III: 6 eq <br />IO <br />&S- � Z <br />HOME or MAILING ADDRESS <br />FAX# <br />/qg <br />ZO <br />!-L_ T— <br />1 (Z ) <br />9 — <br />CITY / _ ] OOl t <br />L <br />STATE <br />ZIP <br />S 2, Z <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 HEALTii DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this Ibml. <br />I also certily 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. t..1 <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESSOVINER❑ OPF.RAT'OR/ MANAGER ❑ OTHER An ruORIZED AGP.NT❑ <br />II APPLIC,INT is not the BILLING PARTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator or 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: (A-5"1- gf!� F-(7— <br />P AYM <br />COMMENTS: <br />RECEIVE D <br />MAY 6 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENT///AL <br />ACCEPTED BY: U(rl 1, Ct <br />EMPLOYEE#: Q3� <br />DATE: (< / D r[ <br />ASSIGNED TO: /IT 0�1,o.-,-I— <br />EMPLOYEE III: 6 eq <br />DATE: S-. roll <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/qg <br />I PIE: a3.0>1 <br />Fee Amount: -1?5. CL) <br />Amount Paid oZ <br />9 — <br />Payment Date oe <br />Payment Type <br />Invoice # <br />Check # 'a ' <br />ceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />