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SAN JOAQUIP', OUNTY ENVIRONMENTAL HEAL? DEPARTMENT <br /> ` SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> D <br /> OWNER/OP TOR r' <br /> :: <br /> X � L r1 CHECK if BILLING ADDRESS❑ <br /> FAciorY NAME , L-� <br /> k)Ar,,4 �.J►,,r� t,,J��. <br /> SITE ADDRESS <br /> SqO <br /> %A/ 9}� / Qt 5'Lq12_ <br /> fTr�t1+y <br /> Street Number Direction Street Name Ci ZiCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Ext. APN# <br /> LAND USE APPLICATION# <br /> I ) — a,� _1'J 40��.�D <br /> PHONE#Z Ext. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> X REQUESTOR <br /> ` CHECK If BILLING ADDRESSES <br /> BDSINESsNAME' �J PHONE# ,� ExT. <br /> lPN 1 3 I'c <br /> HOME or MAILINGDRES FAx# <br /> . D. tS� (?-u,7i _639 <br /> CITY L o C • STATE e^ ZIP q S-2.q / <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 ENVIRONmr-"NTAL 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,Standar TAT id F 12 ws. <br /> X APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICAN'I'is 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 DEPARTNIENT 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: -Su{ <br /> COMMENTS: <br /> PAYMENT ; <br /> �1•i���n� �`��' (fit F2ECEIVEO <br /> DEC 10 2OD9 <br /> J <br /> SAN JOAgwN coU+.,Y, <br /> EWRONMENUL <br /> m <br /> CCEPTED BY: EMPLOYEE#: DATE: . I <br /> ASSIGNED TO: /rte EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed); SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid `' Payment Date (2 ,0 d <br /> Payment Type G , Invoice# Check# _2 Received By: <br /> EHD 48-02-025 SR FORM(Gol en Rod) <br /> REVISED 11117/2003 <br />