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SAN JOAQTTYN COUNTY ENvmo rN r-_V- AL HEAT TY DEPARTMENT <br /> 'Ilm- SERVICE REQUEST r ` <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C/0zS 5� 1 <br /> OWNER OPERATOR � <br /> E CHECK If BILLING ADDRESS <br /> FACILITY NAME (— Vl. <br /> SITE ADDRESS S/ N r j,1,c S j L A L16 Z <br /> Street Number I Direction Street Name ON Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (Z&I) 339— 733Y <br /> PHONE#2 7/ 77 99 Err. CEL C BIDS DISTRICT LOCATION CODE <br /> (0,01 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> /7�5 / o n /(� //O L lock <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I_ PHONE# Ext. <br /> HOME Or MAILING ADDRESS �t FA%# <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: ATE: 7— -20 —Cl <br /> 2 0 —Cl <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/i1 ANAGERff� OTHER AUTHORIZED AGENT❑ a/ /Z <br /> 0 <br /> If APPLICANTisnotthe BILLINGP TY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO —Q?O I: 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: RECEIVED <br /> COMMENTS: v JUL 2 9 2004 <br /> SAN <br /> G 110 mai ,ec✓Isior JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> o.Z,-hujr� <br /> ACCEPTED BY: EMPLOYEE#: DATE: 71141 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P 1 E: 20 / <br /> Fee Amount: � YI Amount Paid It ';D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> \ EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />