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1JH1\ JVH�V11\ t.V V1\I I L'1\YlAVl\lY1L`1\1HL I1L'HL 111 LL`rHl\A 1TJLJ 1\1 <br /> . SERVICE REQUEST <br /> CS6f Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sja4— on <br /> OWNER OPERATOR I <br /> m ba CHECK if BILLING ADDRESS E7 <br /> FACILITY NAME --r 1,,or GAnn (3 -7� <br /> SITE ADDRESS < Lpb u —r hor n- Un P J s4o�nn^ 0'� q'--3-ao� <br /> Street Number Direction Street Name i <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT* PN# LAND USE APPLICATION# <br /> � ) 47g_ MG9 T - 1426 --1 � <br /> PHONE EXT. BOS DISTRICT LOCgTION CODE <br /> REQUESTO <br /> CONTRACTOR/ SERVICE REQUESTORf��o C' M i I L� <br /> CHECK if BILLING ADDRESS C..1 <br /> BUSINESS NAME PHON # <br /> HOME Or MAILING ADDRESS C135 � V V 1 cA V yQ� C 00 <br /> FAX# <br /> CITY LhiZ� STATE L t�S <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 or <br /> 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,S A E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER <br /> El AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is requirelllttt///111 *Title <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. F—N T <br /> TYPE OF SERVICE REQUESTED: ( S r (Z� r4l—CF l RECEI <br /> COMMENTS: I,AAY 1 l 5 Zoob <br /> S�IAY�IN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: i L 1 EMPLOYEE#: ; L/ DATE: -S (/ ;S <br /> ASSIGNED TO: ��/� C �t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): - SERVICE CODE: P 1 E: 7� <br /> Fee Amount• Amount Paid � ' v-� Payment Date <br /> Payment Type Invoice# Check# {a Received By: <br /> EHD 48-02-025 4 SR FORM(.Golden'Rod)' <br /> REVISED 11/17/2003 ` <br />