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±rJANJo AQUIN-UOUNTY L+'NVIRONMEN'CAL-11EA.LTIlsllEI'AIZTMENI' <br /> P <br /> SERVICE REQUEST % i:?(J— <br /> Type of Business or Property FACILITY ID R <br /> SERYICE REQU <br /> S2rJo <br /> OWNER/OPERATOR <br /> FAcam NAME <br /> SITE ADDRESS <br /> I�Ot� �T I u <br /> lr umber Direction SireN Name ZI Code <br /> HONE or MAILING ADDRESS (If Different from Site Address) n <br /> CITY Street Number 5 reN Name <br /> STATE Zip .. <br /> PHONE#f ExT. APN0 LAND USE APPucATIDN# •� <br /> c 1 dcgjb�i�3o .: <br /> PHONE92 Em. BOS DISTRICT LOCAMN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR f <br /> REQUESTINi <br /> A/SPAJ r, CHECK If BILLING MDREss!_]- . <br /> BUSINESS NAME PHONE# �T• <br /> FOv M-0.1 86 <br /> HOME Or MAILING ADDRESS FAA# <br /> CITY )/y a STATE � ZIP <br /> K S32L <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 JoA" <br /> COUNTY Ordinance Codes,Standards,STATE and F®E laws. <br /> X APPLICANT'S SIGNATURE: DATE: G <br /> PROPERTY BUSINESS OWNER[I <br /> OPERATOR/MANAGER ❑ OTHER AUrnoiuzED AGENT❑ <br /> IJAPPMC KT is not rhe R1L1 TNG PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,L the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, gootechnical data and/or environmentaVsite 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: <br /> Commons: fig, n,e , <br /> !' fl Cs7�nc�s2 0 !CQ � VE S <br /> � aL c0 <br /> L <br /> r -- ( 6- C,--6A I 209 17 5- —76 <br /> �y / /� cr z <br /> GCmC �/110ryv/✓ D!"t7[o /S o/1 �C4m��caTza <br /> S G / oa lL / r ENVI IN COIJIV <br /> 7 <br /> ACCEPTED BY: i EMPLOYEE#: DATE: �. <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed yalready completed): SERVICECODE: (OPIE: 2 <br /> Fee AmounUAmount Paid </j Payment Date T !L; ,'r cj <br /> Payment Type Invoice# Check# !/ -7 Received By: ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />