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ENT <br /> 11/19/2004 11:28 9167719255 RHL DESIGN R � �v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> X004 <br /> mNy <br /> SERVICE REQUEST SAN JOAQUW NTAL <br /> Type of Business or Property FACILITY 10# SERVICE REQU TH DE ARTMENT <br /> OWNERI OPERATOR CHECK IfgILLIN�11p>, Pi <br /> FAGILITYNAME ^� o <br /> �caa�1[7Lo C IIILLt75 �2nQ 9to <br /> SITE ADDRESS .14,t,VW W�-tp�}p <br /> Strce4 Name Cf Zi ode <br /> Street Number Direction <br /> NOME or MAILING ADDRESS (If Different from Site Address) <br /> 14 Skroct Name <br /> CITY STATE ZIP <br /> ��2F>r t o <br /> Glav G5 c�/g, <br /> PHONE#1 Cxr• APNA LAND USE APPLICATION# <br /> (91U) 6SE�-u 700 <br /> PHONE92 SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQU ESTOR CHECK if BILLING ADDRESJI <br /> VLAA DQ—re PHONE# EXT. <br /> BUSINESS AME C,IQ <br /> HOME or MAILING ADDRESS FAIL# <br /> I ict I(P) I�X92 S <br /> CITY STATE 44-1 zip <br /> �5 Iccltu.,� <br /> BILLING �4CI;NQWLEDGk;IV%ENT; I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project Specific FNVIRONMENTAL HEALTH DEpAF ri+ENT hourly charges associated with this project <br /> or activity will be billed to me or my busi ess as identified on this form. <br /> Y.also certifj that 1 have prepared th90pET�IoRf <br /> ' d that the work to be performed will be done in accordance with all SAN Jt7AQL1CN <br /> COUNTY Ordinance Codes,StandarDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> t/ I I <br /> PROPERTY 1 BUSLNFSS OWNER MANAGER ❑ OTHER AUTItoRIZED AGENT <br /> ff .PPL CA1y7 is not the B1LL1NG P QZ proof of authnri'zadOn ro sign is required Tule <br /> 4 I—UTHORIZA,TtbN 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 JOAQt1IN COUNTY ENVIRONWENTAL HE•AT,TI°I L)IEPARTNENT 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: <br /> 9 I oc -fes•- - �C <br /> c o W t <br /> ACCEPTED BY: EMPLOYEE# DATE <br /> ASSIGNED TO: it EMPLOYEE 0: DATE: <br /> C( <br /> Date Service Completed (if already completed): SERVICE COM: 1 �- P f E: Z3 <br /> Fee Amount: — Amount Paid �—�C� — Payment Date I t Z D <br /> Payment Type L--- invoiceb! Check# 7L 4 ELS Received By: 2� <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />