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SAN JOAQUIN"-'OUNTY ENVIRONMENTAL HEALTY nEPARTMENT <br /> SERVICE REQUEST r <br /> Type of Business or Property FACILITY ID# s SERVICE REQUEST# <br /> .5'I2-c'u 3Gl -?-)-I <br /> OWNER/OPERATOR <br /> G Q 6 �^A n M C CHECK If BILLING ADDRESS12 <br /> FACILITY NAME r 1� J <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) p v Q 75'� <br /> Street Number Street Name <br /> CITY / � Al ir-� STATE ZIP 7 <br /> PHONE#'l G' EXT. APN# LAND USE APPLICATION# [� <br /> (Zoq ) 7,?-7 - S64$ 2-6 M s c <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1<0"4 CHECK If BILLING ADDRESS <br /> t <br /> BUSINESS NAME 5166F/Ltc 0 �N <br /> 6AI6/NdG <br /> /V C- PHONE# Exr.( W ) <br /> HOME or MAILING ADDRESS U / FAx# <br /> `� �S Co2o�✓ 0 .qr/ - ( Z-0q ) `11(2 - 0 ?-/ <br /> CITY ( <br /> ac <br /> o� STATE ZIP qs -0 <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 laws. <br /> APPLICANT'S SIGNATURE: f,Jg w DATE: 94'9 / o g- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 DEPARTMENT as soon as it is available and-Q4"1/s tftme it is <br /> provided to me or my representative. ICE <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Q�tiL � �DM I IIN COUNTY <br /> HEALTH DEPARTMENT <br /> y8 <br /> ACCEPTED BY / EMPLOYEE#: C DATE: gk OL <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -� P 1 E:)Lo <br /> Fee Amount: r Amount Paid �� Payment Date ! �� <br /> Payment Type Invoice# Check# '763 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />