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SAN JOAQUI 'OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ /ve <br /> (ER (� C =if§ILLING ADORES <br /> S <br /> FACILITY NAME <br /> SITE ADDRESS S v%A I (• �i:cr r: 'l el �- C.� <br /> Street Number Direction Street Name ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR )N& A ` , � , _ 4 410 CHECK if 13ILLING ADDRESS E] <br /> BUSINESS NAMEPHONE , FXT• <br /> S,T. l.��E1}i�FG_ �:.y��.�Q, .�rtti: ti� (�;6: ) ,Yi(� - 5`1 <br /> HOME or MAILING ADDRESS S <br /> f lis f4 v I o` (S&L ) b <br /> CITY STATE 4 A ZIPr— <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 or <br /> 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 a EDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C �•i.� <br /> If APPLICANT is not theBILLINGPARTY 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. �/1 <br /> TYPE Of SERVICE REQUESTED: ({ST I� 1 �` �' t t <br /> PAYMENT <br /> COMMENTS: HEUEIVED <br /> APR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L I U,�{ EMPLOYEE M C) 1•Z DATE: S U <br /> ASSIGNED TO: V EMPLOYEE M (!L3/-7 DATE: cf (.S(G <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: C Si <br /> Fee AmoVnt: - ;L7 ��t4 I Amount Paid d 7--7,CO Payment Date yl is/pv <br /> Payment Type V% Invoice# Check# ] �( Q Received By:` <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> oaviccn iiii-7nnnz <br />