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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3972— 'i Z,29537?5 <br /> OWNER/OPERATOR <br /> . CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> C <br /> SITE ADDRESS {1(_') �- <br /> Streel Number Direction Street Name " _O Z C de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> (240q) Lq ka S 1 /17-3/0-0/ <br /> PHONE#2 EXT. SOS DISTRICT LOCATIO CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> _ .4 <br /> HOME or MAILING ADDRESS FAX# <br /> lD �l1 E l �U�e �or� . ( ) ?vCaS - ISti3 <br /> CITY STATE QA <br /> ZIP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,Standar r,STAT,and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: '3 `a Fs I�— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LaT e e . <br /> /f APPL/CAN'P is not the BILLING PARTY FlrOaf Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: (�(.ST ,�£?'��i (T -PAW <br /> COMMENTS: G10 vt � fE ,-ED <br /> MtiR 31 (UVJ lUl\w/J <br /> f�oaQQ/ �oQd MAR W 1 [008 <br /> H�tryoF"'FCO'1JVryENV <br /> J TW <br /> ACCEPTED BY: D L[ V [ �}} EMPLOYEE#: Q 3' EAT IT <br /> ASSIGNED TO: '-�j�t��Li EMPLOYEE#: OOD DATE: 3 31 or <br /> Date Service Completed (if already completed): SERVICE CODE: /'?k IE: 7 o Q d <br /> Fee Amount '�, f7L) Amount Paid cj Payment Date <br /> Payment Type L. Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />