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• SAN JOAQUIOWNTY ENVIRONMENTAL HEALTARTMENT <br /> SERVICE REQUEST a <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S �e5 (Jn <br /> OWNER I TOR r <br /> / O C„ ,! C" CHECK It BILLING ADDRESS <br /> krzi <br /> FACILITY NAME NCS f th t/ G-6 <br /> SITE ADDRE=Sri l• ` 1 9 �..L�i y� <br /> " 35W Street Number DI tion l/` Stree�ame � o CI Zip Code <br /> HOMEQor M[A_ILING_ADDRE S (If 9iffere t from/$Ito/Ad ress) <br /> tj /7 (H Wd l.. Y Street Number Street Name <br /> CITY 64$y-\ <br /> / � STAT ZIP -S^ _ <br /> PHONE#1 t,C ExT• APN# LAND USE APPLICATION# <br /> ( 660) 2&G- 37gZ <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> i fN41 � ��M oW �jNET CHECK if BILLING ADDRESS <br /> BUSINESS NAME V / �,/ t 1-/T PH <br /> N60I /- �j 9 F S� <br /> EXT. <br /> HOME Or MAILINQ ADDRESS –T �'l14 (AX <br /> l) V��� — <br /> CITY Y !SM 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 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 Fe RAL la - <br /> APPLICANT'S SIGNATURE: - DATE: <br /> / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGErs;r <br /> If APPLICANT is not the B/LL/NG PARTY proof of authorization to sign is required Titre <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: REC+EIVEnntDtt��tt <br /> COMMENTS: FEB 17 20 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: vohl <br /> ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: S Amount Paid t$ 3) 5-"-- Payment Date 71 <br /> Payment Type ✓ Invoice# Check# 17-7,46 Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />