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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTTT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID X S VICE REQUEST II <br /> OWNER/OPERAT CHEGtN RUNC Pmts <br /> LGKLT CLQ/ J <br /> FACILITY NAME <br /> Sff EADDRESS ///Cf/�GL`/PN / E• JJ D �/tJ l c�<� <br /> � SF+e.T h <br /> Stmt Name <br /> HOME or MARm ADDRESS IN Different from Site Address) <br /> Street Num treat Name <br /> CITY �.�w STATE LP <br /> PHONE III APNi LAND USE APPLICATIONS <br /> X ' c— <br /> PNON Em BO$DISTRICT LOCATION c <br /> ( 9 ?L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R1QUESTtM <br /> CHECK H BILLNIG ADORES$ <br /> DDSINESs NAME PHa1E i E"'' <br /> HOME or MA1uNc ADDRESS FAx 0 <br /> 1 1 <br /> CITY STATE ZIP r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> r acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. `n <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQtltN _ <br /> COUNTY Ordinance Codes,SrandOds,ISATE and FEDERAL laws. ,/ <br /> APPLICANT'S SIGNATURE: P _ O DATE: I —I T t� <br /> PROPERTA/BUSINESS OWNERP, OPERATOR I MANAGER ❑ 0TRERAUTHORr7 DAGENT'� <br /> JjAPPL! i5-ht the BILLING PARTY proof of authorization to sign is required Tirte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> — 14 <br /> TYPE OF SERVICE REQUESTED: lN7 L I'? rlr—;,1�� <br /> i <br /> COMMENTS: � /, � S �- � C <br /> ,� (�, ((, -41 <br /> EC 15 2004 <br /> kv— 14Ae aT. I Lam' � 7� � 1 �{Z.•V �' S Z1� S�JOgQUIN CpU <br /> ENVIgp NTy <br /> HEALTH DF E M NT <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: A ' EMROYEE#: h ` DATE: <br /> Date Service Completed (H already o Noted): SERVICE CODE: PIE: <br /> Fee Amount: l Amount Paid Payment Date <br /> Payment Type ^ C� Invoice# Check# Re etved y: <br /> EHD 48-02-025 <br /> REVISED 11/172003 SR FORM(Golden Rod) <br />