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SAN JOAQUI, OUNTY ENVIRONMENTAL HEALTH . .PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME j f�^ Cac c <br /> SITE ADDRESS v1 q C` N J <br /> k_-Q_tf(-C.V►kQ LX �6� el- <br /> Street <br /> oL- Street Number Direction Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> x,2©9) 3h , <br /> PHONE#T EXT. BOS DISTRICT ' r LOCATION, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Lk�\ �; f t �w-a,y1 CHECK if BILLING ADDRESS@ <br /> BUSINESS NAME +LPHONE# EXT. <br /> 7'iLc . (46 ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Q L� �Qs k STATE Ch ZIP Q�_l/� <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 HEALTi-I DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 01'[1i17C117Ce COCIeS,S/ClndC!/'dS, STATE and FEDERAL laws. <br /> APPLICANTS SIGNATt1RE: ti ( LLILC �.�hi-2-L� <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR MANAGER ❑ OTHER AunioilIZGDAGENT CL! ce.uue,L6+(,CAE. <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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 HEALTI-I DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. A 12 <br /> -` <br /> TYPE OF SERVICE REQUESTED: Oc-_C L" P c+fc c <br /> COMMENTS: 't�Sf q� �TfLlL� 1 U [QUU <br /> jUN <br /> SAENOIAQUIN RONME O TM <br /> AL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: OL t l/ t EMPLOYEE#: 3 DATE: f 0 (G k <br /> ASSIGNED TO: tQ C I(—,-" EMPLOYEE#: `tom 3 DATE: t C, vtb'/ <br /> Date Service Completed (if already Completed): SERVICE CODE: ,C/?C� PIE: �Z 3 <br /> Fee Amount: �cr T v'7i Amount Paid a 00-C Payment Date (� p <br /> Payment Type ✓ Invoice# Check# 2- '7 Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />