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SAN JOAQUI` —OUNTY ENVIRONMENTAL HEALTH' "ARTMENT <br /> SERVICE REQUEST <br /> ' T of Business or Pro rh/ FACILITY ID# SERVICE REQUEST# <br /> 701�efri; 0un iG( <br /> OMER/OPERATOla- <br /> L-�A <br /> CHECK If BILLING ADDRESS <br /> FAclurY NAME win , e � v� <br /> SITE ADDRESS 153, l� 5& <br /> Street Number Direction `j'T�P t I l�M tCi C Code <br /> HOME or MAILING AWxSS Af Different}from Slte Address) <br /> VC) boy J U Street Number stmet Name <br /> CITY STATE <br /> Lwu `�52W/ <br /> P E#� Exr. APN# LAND USE APPLICATION# <br /> ��, <br /> PtioNE#2t33 3-- -<-OV 740^ BOS DISTRICT LOCrDE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ir' <br /> ,^ puum&t& <br /> CHECK if BILLING ADDRESSBUSINESS NAME f1 � U '� P Y A-7Z'�eI3 Exr. <br /> HoMF,orMqJNG ADDRESS F # <br /> �K,re Sa �9-r I /�) 3�Z- ?3 <br /> CIN 9S L 5aC*-x STATE (5)_G�/,ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator orauthorized 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 and FED S. <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINEss OWNER 5OPERATOR/MANAGER ❑ OTHER AUTuoRIzED AGENT❑ 4,7 1;,4, <br /> !fAPPLICANT is not the BILLING PARTY—proof of authorization to sign is required 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />