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0 JANJOAQUINUOUNTYENVIRONMENTALtMALtki )LtPAIK tvrciFi <br /> SERVICE REQUEST <br /> Type of Business or Property /t FACILITY ID# SERVICE REQUEST# <br /> ! 1! /�T /p /o/ IP �S ate.CD 533IS <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSEJ <br /> -A a eop, eZ <br /> FAZUN NAME �— <br /> 71 //c 630 yg woS <br /> SITE ADDRESS <br /> Street Number Direction Sireet Name City 5 to Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> (f D - C7 d SUM Number Street Name <br /> CIN <br /> Zip <br /> C t� t CAT '9 5'2 u l <br /> PHOK#t EM APN# LAND USE APPLICATION# <br /> (7o9) 0637x71 1-2 °I— ISa-7—(e f'A - 0-7C)M)Sq � CSt¢ <br /> PHONE#2 Exr. 4BOS DISTRICT / LOCATNp C DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ex'' <br /> HOME or MAILING ADDRESS FAX# <br /> CRY 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 JOAQUN <br /> COUNTY Ordinance Codes,Standards, TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: y � DATE: <br /> PROPERTY/Busmmss OwNERU OP RATOR/MANAGER ❑ OTHER AuTnoRtzED AGENT❑ o <br /> If APPLICANT is not the BILLflVGPARTY,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 environmentallsite assessment <br /> information to the SAN JOAQUN 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: /�I l�-k y[_. Lo AQ d t So f C- S e -L T'48 4 L <br /> COMMENTS: 3141o? , <br /> 4 o? RECEIVED <br /> �Ja� MA:i - 4 LUUB <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAITH DEPARTMENT <br /> ACCEPTED BY: QL_t t EMPLOYEE#: &J 3 2—� WDATE: 3 <br /> 14-182 <br /> ASSIGNED TO: F—..� EMPLOYEE#: ^7 '3-z D k' <br /> Date Service Completed (if already completed): SERVICE CODE: 5-2 (0oFee Amount: `��O ,tTZJAmount Paid Payment DPayment TypeInvoice# Check# <br /> \� EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />