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SAP _ ENVIRONMENTAL HE <br /> SERVICE REQUEST <br /> Type of Business or Property , l FACILITY ID# SERVICE REQUEST# <br /> ,VQ L,J Cd51 Ien II/rStou �S*W`40360 <br /> OWNER/OPERAOR <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME l ) + <br /> �J I Gc►doc{ �`�Ti� IP 5 5�,.�/j�tft51 Din <br /> SITE ADDRESS'^ AJ <br /> C� / 1 A S �j <br /> 13 O Street Number Di..tion W"V7 WO Street Name ` ' _ �� Ci V��/ `ZI ode S 9 <br /> 1 HOME or MAILING ADDRESS (If Different from Site Address) 1 <br /> o' ZS c, Street Number Street Name <br /> CITY STATE <br /> zip � <br /> q'17 zSg <br /> PHONE#1 ExT• APN# ?146­LSE APPLICATION# <br /> 112,571 ) 33�- C�1S - o2v -�l <br /> PHONE#2 EXT. OS DISTRICT ATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME �- i PHONE# �� j ExT• <br /> - <br /> HOME or MAILING ADDRESS FAx# <br /> C (2v`1) 33(1- '2,V47 <br /> CITY STATE (Z <br /> , ZIP Q 52—Sg <br /> BILLING ACKNOWLEDG MENT: 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �Title'IfAPPLICANT is not the BILLING PARproof of authorization to sign is required <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: S !� >yC r� S' g <br /> COMMENTS: HIzOEIVED <br /> Edi � �y ► 3 � <br /> NOV 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAL <br /> ACCEPTED BY: 0 L-I �,ice( EMPLOYEE#: O 3 Z I DATE: <br /> ASSIGNED TO: '.� N LI EMPLOYEE#: �r j(1 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: �� P i E: / i, <br /> Fee Amount: L (x) Amount Paid L U Payment Date <br /> Payment Type C l.4 eC K- Invoice# Check# G / Received By:(f-- J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />