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SAN JOAQUI* "OUNTY ENVIRONMENTAL HEALTa'T)EPARTMENT <br /> L' SERV CE-REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> 6Raa43�3�- <br /> OWNER/OPE TOR CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ,7,V d R F- r\ X107-12 h 6 8Q <br /> J � � � city Zip Code <br /> Street Number DireeNon Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PNONE#t APN# LAND USE APPLICATION# <br /> PHONE#2 �T• BOS DISTRICT LOCATN)N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS D <br /> �- <br /> BUSINESS NAME PHONE# Ext <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 speck 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 applicati" and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,$,T and FEDERAL la <br /> APPLICANT'S SIGNA'T'URE: - DATE: <br /> PROPERTY/BUSINESS OWNER❑6--�-OPERALTQAl ❑ OTHER AUTHORIZED AGENT❑ / <br /> 1fAPPLICtNTisnottheBlLfTkGPARTY 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 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: 4L S P <br /> COMMENTS: moi'./ � 2005 <br /> AUG 2 <br /> � K / SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 112 <br /> ACCEPTED BY: EMPLOYEE M DATE: Fill-3/0 <br /> ASSIGNED TO. EMPLOYEE M DATE: <br /> Date Service pleted (if already completed): SERVICE CODE: SZZ PIE: <br /> Fee Amount: Amount Paid Z gl"�o . C) L) Payment Date a-3 <br /> Payment Type Invoice# Check# Received By: 2,/— <br /> EHD 48-02-025 _ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �- <br />