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SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH (DEPARTMENT <br /> ` SERVICE REQUEST <br /> 'Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> va <br /> SA CHECK If BILLINGADDRESS <br /> FACILITY NAME <br /> � <br /> —USA -C�N-Ann 13b,116 <br /> SITE ADDRESS 2 y,9/2 lJ.: <br /> ke.*Namun LaN.rl ,GGC �s ode <br /> Street Number Direct,.. Street Name CityZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> (2C>1) 369- 3!24 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> L <br /> HOME or MAILING ADDRESS FAX# <br /> 1 %-A -1-0 Lf`7 (24: ) 3 6Y 453 <br /> CITY STATE ZIP <br /> Z <br /> BILLING ACKNOWLEDGEMENT: I, 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 fon-n. <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 JOA01JIN <br /> COUNTY Ordinance Codes,Slanclards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA'T'OR/MANAGER ❑ O-rimit AUTHORIZED AGEN'r A <br /> ff lI PPLIC ANT is nnl 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 al the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS; RECEIVED <br /> JUN 17 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: /' DATE: ,j'j <br /> ASSIGNED TO: ? EMPLOYEE#: tl/ DATE: (Y <br /> Date Service Completed (if already complet d):j SERVICE CODE: /m P/E: a-op <br /> Fee Amount: —� Cf Amount PaidOV_ Payment Date 7hq <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />