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e SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SDI 9?? SP'004(o 15 <br /> OWNER I OPERATOR0 - <br /> C/iY7iT! CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS LCr7f/,y G Q <br /> Street Number Dierdicn Jt r/St(re/e0 NYalme CI / ZI Code <br /> HOME pr MAI ING ADDRESS (If Different from Site Addr SSI <br /> JV 7/f <br /> Street Number � Street Name <br /> CI STAT ZIP <br /> PHONE#t E-' APN# LAND USE APPLICATION# <br /> rw ) '7 / D�- I 2p <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> ( ) 3&Q - /32 , <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME L p(TV) <br /> EXT' <br /> i <br /> HOME IONLING ADDRESS FAX# <br /> ( Y ) <br /> CITY STATE ZIP `! <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized✓1agent 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 applicationpnd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE �d FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: j �� DATE: �3- �e ' <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER + OTHERAUTHOmZEDAGENT❑ PP`, N -1) <br /> IfAPPLicANT is not the BILLING PAR TP proof of authorization to sign is required n� Title 11 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator o��fah <br /> AA @@��pl)ftr�Aated at the <br /> _ above site address, hereby authorize the release of any and all results, geotechnical data and/or eANs mental/site ANWssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availal lh��(Jtft1� ,time it is <br /> provided to me or my representative. SAtVENVIFONP RTMENT <br /> TYPE OF SERVICE REQU�E/S�T/.ED:,/]�01 <br /> gr,/ <br /> C/OMMM�ENTS: l+�'I i 9//t.r//4!/f�L�<'�rf af.L/!V/�( � / /T,�i✓ry yr v/� V// ��'r r/v^aA CL�J' <br /> t57` Z.,`-` &A57 AL-7blTtiv rz-'a4v Mun 'a5 u. vF zotL <br /> Fri 4;5- ron" � 4) ov�L 4M rvez-s e Veru, �.&/ <br /> DlS�bzs , vlk'(7� 4-mnl4-zE IV zap <br /> ACCEPTEDBY: - EMPLOYEE#: F3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: `a DATE: <br /> � I on? J <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 Fj <br /> Fee Amount: Amount Paid 0 LA 3 U�I, Payment Date 3 2 <br /> Payment Type ✓ Invoice# Check#q�(�`�� g" Received By: <br /> EHD 4e-02-025 SR FORM(Golden Rod) <br /> REVISEL 11/17/2003 <br />