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SAN JOAQU —�OUNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c-- 5 — w SKOo ss 9 9�' <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> ITE ADDRESS E �. Y L GZ 1 l f_ 15+DcJ--+bn Iq5a•i L) <br /> U - L-• Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -PeLOS+ - <br /> D Street Number Street Name <br /> CITYI � 1 ZIP PHONE#1 V EXT. APN# �iLAND USE APPLICATION# <br /> � ) 04 _ zi�—zv <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> cwt) $ 1 - g`-ILI � 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> AM �? Ss atm - bL- <br /> HOM E or MAI ADD ES F�Ax# ) _ `-'/ <br /> n <br /> CITY STATE ZIP Lo <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 <br /> or 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: 9 DATE: 1 i o <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CA T 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �—"06 L A-ej C P C— CCC— <br /> COMMENTS: v�1 t r l LA1 �� y1tw �K Y � bei-r 09NV4 <br /> Nv'M EP'��N <br /> Nom" <br /> ACCEPTED BY: L L v ElA EMPLOYEE#: Z f DATE: / Z//7/r"/ <br /> ASSIGNED TO: A EMPLOYEE#: Z DATE: /L <br /> Date Service Completed (if already completed): SERVICE CODE: CZ P 1 E: f�� <br /> Fee Amount: s',L li Amount Paid 7$3 s O� Payment Date C 1-7 <br /> Payment Type Invoice# Check#3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />