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SAN JOAQUI%�NTY ENVIRONMENTAL HEALT� j ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c�SERVICE REQUEST# <br /> K c�,2 S E S L- S ✓e / Q/ <br /> OWNER i OPERATOR CHECK if BILLING ADDRESS❑ <br /> D�G-L a 7-od es c 611V <br /> FACILITY NAME -] _ <br /> 14C <br /> SIT 1- <br /> ESS <br /> Street Number Direction Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (If Different from yS.ite AAdr)Qss) <br /> �J 66 /� x-2-1 ' `(J Street Number Street Name <br /> CITY ST TE ZIP <br /> Ra j - d <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#Z En. BOS DISTRICT LOCATION ODE <br /> (W) - Z8 Z f4-X <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATUR �j� <br /> E: DATE: <br /> PROPERTY/BUSINESS OWNER 9 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tine <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. — T <br /> TYPE OF SERVICE REQUESTED: (�(,(/ � �, l\ P.Ebelv2D <br /> COMMENTS: <br /> APR 12 2005 <br /> -SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ®L-t L LC I 1,;, EMPLOYEE M 0 3 2 DATE: (�� 11 & <br /> ✓I <br /> ASSIGNED TO: I--tC CC-. L 0 J EMPLOYEE 3 '`-?—S DATE. 1 1 Z. 0 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I "�.. <br /> Fee Amo4n • t27 _ Amount Paid $ G� a Payment Date Y yLvs <br /> Payment Type Invoice# Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - - <br />