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SAN JOAQ- . COUNTY ENVIRONMENTAL HEAL?_ JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -OWNER/OPERATOR <br /> 5�1 O r S�,JO e-A.A CHECK If BILLING ADDRESS <br /> 191, <br /> Z>iTyNAME OO Ti ri+ <br /> ACIL <br /> SITEADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3 '_` 'T V C 'Street Number Street Name <br /> CITY11 STATE ZIP <br /> --rOC—V-^C b�� CAr- S <br /> PHONE#1 EXT. APN# ` LAND USE APPLICATION# <br /> (*Uct) 84'1 — �'�-9 1 o '� <br /> PHONE#2 EXT. BOS DISTRICTo + LOCATIONICODE <br /> ( ) l `l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 ENv1RoNMENTAL 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 FEDERAL laws. <br /> APPLICANT'S SIC,dSi.Aa + <br /> URE- ���P� �LG 6e,P- AA-TE—. — Z' f <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY.proof 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 1b9,%=e time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Ov W k X71 bt A <br /> COMMENTS: SAN <br /> HE4 2414 <br /> OMNDAlq N <br /> paRTMFNT <br /> ACCEPTED BY: ( � `' EMPLOYEE#: DATE: -,r Z Q l l <br /> ASSIGNED TO: \ !V I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J P/E: <br /> Fee Amount: t Amount Paid a� (>D Payment Date 3 <br /> Payment Type 4 A el Invoice# Check# Receiv d By —' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />