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SAN JOAQUT_ COUNTY ENVIRONMENTAL HEAL- 'DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Iz16 u L Tu _G S ,EA/T G� L <br /> OWNER/OPERATOR <br /> �2 - TOIV U7RA CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS 3�8U 7r—/NN/^J /-?R A/TEC.Q95 3 3, <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APP KATION.# _ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE, QUE <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> w 8-(4y <br /> HOME or MAILING ADDRESS FAX# <br /> P.o _oox 3 7141 ( ) e�� -2 <br /> CITY --r—tx 1Z L-06 L STATE 6� 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 applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, Tp, <br /> and FED aws. <br /> APPLICANT'S SIGNATURE: DATE: — _v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGTOrrization <br /> HORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,prsign 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 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 REQUE TED: S'afZf-AGS S i3Su2F G D t�1/A//lT/O� <br /> COMMENTS: oOS <br /> 13 <br /> ACCEPTED BY: L( L t EMPLOYEE It. C)z,L 1 N DATE: <br /> ASSIGNED TO: iJ /U,c EMPLOYEE#: L,�� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 t S i P 1 E: Z(a.�z <br /> Fee Amount: 8'(o. Amount Paid I �� v Payment Date D <br /> Payment Type Invoice# Check# Received-By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />