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SAN JOAQUIN , _UNTY ENVIRONMENTAL HEALTH L- ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F13--D600//0 0 4-/ <br /> OWNER/OPERATOR <br /> —Z/n -,4 / / CHECK If BILLING ADDRESS <br /> FACILITY NAME -j—SL ` <br /> SITE ADDRESS S//S <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) '0 U. 1507 <br /> Street Number Street Name <br /> CITY STATE Z4 ZIP <br /> PHONE#1 ExT• APN# <br /> LAND USE APPLICATION# <br /> (dcyI) y7v. is11i <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS O <br /> BUSINESS NAME PHONE# Exr. <br /> 7�ENE29L �,cll!/20��YCSTc L /yArJ•9l�CF( S ly CC-5 —xS <br /> HOME or MAILING ADDRESS FAX# <br /> CITY / au' y STATE ZIP <br /> 9�s6 s <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 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,Standar STATE and FEDERAL laws. c <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER LJ 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C�S T o t T RE Enj <br /> COMMENTS: <br /> MAY 3 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTq� <br /> FIEALTH DEPARTMENT <br /> ACCEPTED BY; C) EMPLOYEE UI EMPLOYEE#: S 2. DATE: <br /> ASSIGNED TO: GU I LSO/J EMPLOYEE#: < � CIS DATE: S l c.S <br /> Date Service Completed (if already completed): SERVICE CODE: �y g P1 E;23 �9) <br /> Fee Amount: -��9 Uc� I IfAmount Paid �r9� Payment Date 3 �� <br /> Payment Type ✓ Invoice# Check# 8 R cel ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />