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SAN JOAQUil- "OU'NTY ENVIRONMENTAL HEALTT- IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT /� <br /> //`/ CHECK if BILLING ADDRESS <br /> FACILITY NAME {''(" t <br /> SITE ADDRESS GI 71 gs / W , U—Q r'tJ Y8V�' F-/r. O!'Y� 157/'(/&14 <br /> Street Nu bei etion Street Name Cft Zip Code <br /> HOME or MAILING ADDRESS (If Different-from Site Address) D <br /> Z b 2 v`/ C H U/S r�a Street Number Street Name <br /> CITY Q / $TAE LP 6 3 z <br /> PHONE#1 ; Exr. APN# LAND USE APPLICATION# <br /> (boy) I ?o (v ae�t -i�Fo-oma ori ,Ohs G�5' - 3s <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE RE§NESTOR <br /> REQUESTOR <br /> �//` CHECK((BILLING AD 5 <br /> BUSINESS NAME .4� 1 t� P ,`� '?-3 _ / 3 75— Exr. <br /> HOME or MAILING ADDRESS C x# <br /> `� FAx <br /> �5 3 5` Solari /2,Z, (act ) 9'vl " Z 3 7 <br /> CITY /_. C11- <br /> -. -C� STATE /+:Q ZIP g�24 <br /> BILLING AJCKNOWWLLEDGEMENT: 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 of <br /> activity will be billed to me or my business as identified on this form <br /> '3 <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 JOAQurN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: [ _ (F "`" — DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTRERAUTHORIZED AGENT® <br /> 7fAPPmcANT is not the BILLING PAR 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 JOAQUDJ 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 SERVIC t*tiE T D: �✓L< <br /> COMMENTS: 7- <br /> /liF � R CEIVED 63 D nates <br /> // L 1 <br /> 20 t,l. 9 2005 <br /> lt�U RpNIN COV OS ( '-'�� / I' g AOUIN COUNTY <br /> HOFPgEAti'gN7y /Q.5— /'acyc' —,R CFO _ AL <br /> ACCEPTED BY: Q L(V k I re—,J EMPLOYEE M p 3 Z-I DATE: /I O`U�' <br /> ASSIGNED TO: ME,3 / ,v� 1 _ _ EMPLOYEE#: S j�, DATE: / ( t)�-- <br /> Date Service Completed (if already comple SERVICE CODE: S 2, 1�7i P 1 E: <br /> Fee Amount: & C 0 �$Tt1T' A ount Paid 0 b , O O Payment Date <br /> Payment Type Invoice oCheck# L..'. 3 Received)By. <br /> EHD 4M2-025 \�b p �\I SR FORM(Goldeen Rod) <br /> REVISED 11/17/2003 <br />