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SAN .JOAC 1 COUNTY ENVIRONMENTAL HEAL. 'DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Co-n�.S a5 ��t� �0 9'P9 5levobss' � <br /> O ER( PERA�T1O1R <br /> )oC* M CHECK if BILLING ADDRESS <br /> FACLrrY NAIYIE <br /> ..0 <br /> SITE ADDRESS <br /> Stieet Number Dhectlon �J St+eet Name ��� ��� <br /> HomE Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet NnnO'e+ Street Name <br /> CITY <br /> STATE zip <br /> PHONE#1 EXT. APN# <br /> ^�, �� _� LAND USE APPLICATIOIJ# <br /> ( <br /> `l <br /> PHONE#? EXT. <br /> 1. BOS DISTRICT LOCATION CODE <br /> CONTR=WTOR / SERVICE REQ>LTESTOR <br /> R EO UESTO <br /> �{�. 0-e 1\A* CHECK if BILLING ADDRESS <br /> PHONE <br /> BUSINESS N ME ' # EXT. <br /> ��. nS t )Ste{ - 131 <br /> HOME o AILING �\DDRESS FAX# <br /> CITY STATE 7— <br /> BILLING ACKNOWLEDGEMENT: i, the Undersigned property or business owner. operator or authorized agent of same. <br /> acknowledge that all site andior project speclfc ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> acti\Rywill 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 clone in accordance with all SAN JOAQUIN <br /> COUNT' OtV,,nance Codes, Standat'ds. STATE and FEDER4WSAPPLICANT'S SIGNATURE: DATE:PROPERTY/BUSINESS OWNER RATO /MANAGTHER AUTHORIZED AGENT I I <br /> If APPLICANT'S 170t the BILLING PAPT! 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data anclior emAronmentalisite assessment information <br /> t0 the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Sallie time It IS provldecl to me Or <br /> my representative. <br /> 0 <br /> TYPE OF SERV STED: <br /> C OFMIE 00 19a <br /> � 16113 �M <br /> NO V 2 6 ?013 <br /> GovN� ENUIROIU <br /> sPN N v"° a�Mt P�RMI T �V�FS rH <br /> kN {t)VP <br /> ll <br /> ACCEPT 1': EMPLOYEE#k `7t_ f f ( ppTE; L/ �� <br /> ASSIGNED TO: EMPLOYEE# �`--ii�7J!J�j(J DATE'.: )(�7 <br /> Eee <br /> Service Completed (If already Completed): SERVICE CODE: 7�10 <br /> ount: 1006 Amount Paid 1()60 � Payment Datet Type Invoice# Check <br /> � Received By: <br /> Gov <br /> EHD 48-02-025 <br /> ^^ SR FORM(Golden Rod) <br />