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SAN JOAQUIN "7UNTT'ENVIRONMENTAL HEALTILDEPA.RTMENT <br /> SRRVICE REQUEST �- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Q <br /> AJ` CHECK If BILLING ADDRESS <br /> Q Q I <br /> FACILnY NAME <br /> Lt/ / -� Street Number I Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ?Z9Ck j D . / (IjA STATE ZI� <br /> PHONE#t V l� T fV EXT' APN# /T LANDAE APPLICATION# <br /> (.209) — 70 <br /> PHONE#2 E.I. BOS DISTRICT LOCATION CODE <br /> (R10) yY — c;207S-- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I V ) L C 11 ECrp CHECK If BILLING ADDRESS <br /> BUSINESS NAME V 1 r� ,T PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> orn/C� /'eve ( ) <br /> CITY E 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 nd that the work to be erf Tined will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATEA5yFEDE laws. /� <br /> XAPPLICANT'S SIGNATURE: L DATE: 152 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BILLING PARTY Proof of authorization to sign is required Tirte <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. <br /> TYPE OF SERVICE REQUESTED: St� Falc-E <br /> COMMENTS: r, �].. ,,.�„✓ r�tk �60 Flo '` - RECEIVED <br /> 3� OCT 3 M5 <br /> 1 <br /> SAN NVIRONIMEN AL <br /> xW p RTMENT <br /> ACCEPTED BY EMPLOYEE#: DATE: d <br /> ASSIGNED TO: MPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE C D : IS PIE: ZG,0-1 <br /> Fee Amount: (8(0 . pC) Amount Paid (FL a � Payment Date /u ;;/C <br /> Payment Type ✓' Invoice# Check# b Received By: 7a,K— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />