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SAN JOAQUIY 47OUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> DAIRY -ANI�, TARtA I R <br /> OWNER/OPERATOR UA N NY H A CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME DA N Mf f��t�] DAIRY <br /> SITE ADDRESS 2.059 P <br /> A <br /> RA <br /> t isA�r�u� �Y 953�- <br /> Street Number Direction Street Name CitV Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex-r. APN# LAND USrPATION# <br /> (2c�9> 321—9BEi2 H/A 213• -22.2 � <br /> 7,2e, �f 31 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> WA�-TER !v.�uR-T15 <br /> BUSINESS NAMEPHONE# ExT' <br /> c R"1-1 s N G t+a.i 1✓ R l ra c� 2,793f�8-- 41�9 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY L STATE e-.A ZIP 91L4-L--) <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 SIGNATURE: DATE: 0�1I7LO3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTO <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <f E4 I try� 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:" RI�M{EJ.r' y 11=-:y-1 <br /> COMMENTS: , 2�/?43 <br /> ►� r APR 17 2003 <br /> SAN JOAJUIN COUNTY <br /> PUBLIC H ?LTH SERVICES <br /> W4 POo <br /> APPROVED BY: EMPLOYEE#: �/� DATE: <br /> ASSIGNED TO: i/ fZ�,E! EMPLOYEE#: of ell l DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E:,2(o 03, <br /> Fee Amount: Amount Paid 7� 0,0 Payment Date <br /> Payment Type Invoice# Check# Received By:�/ j <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />