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MAIN JUAVU11N k-UUIN1 Y r1NV1KkJiNIYIE1NIAL nLALI17 "VrAKtiVMI-41 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 52aogg3&3 <br /> OWNER OPERATOR 9 / <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /'77 {%/jam// <br /> Street Numbel Dire`et/lo/n L Street Nama / / city Zip Code <br /> HOME r MAILING ADDRESS (If Different from Site Address) <br /> / / Street Number Street Name <br /> CITY / STATE ZIP <br /> PHONE#1 G � �Ev. _ I APN# �� LAND USE APPLICATION# <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr_ <br /> HOME Or MAILING ADDRESS FAz# <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 projector <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 SIGNATURE: k _� DATE: lle9 <br /> �— <br /> PROPERTY/BUSINESS OWNER OPERATOR� /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLIC T i4 not the BILLING PARTY 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. <br /> TYPE OF SERVICE REQUESTED: SOIL S-tt (TY' 1U STZd 4;) RECEIVED <br /> COMMENTS OCT 14 2005 <br /> SANOCOUNTY <br /> \�73� ; M�•- <br /> ENVIRONMENTAL ENTAL <br /> �014 � A T HEALTH DEPARTMENT <br /> ACCEPTED BY: Oc-L LC- t EMPLOYEE M O ) DATE: (0 [l+ 6s" <br /> ASSIGNED TO: ,'A-/v 6./NE EMPLOYEE#: [FG,fj7� DATE: (0 ftf <br /> Date Service Completed (if already completed): SERVICE CODE: 6-22— PIE: 20 <br /> Fee Amount. �� ,p� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />