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�����rr�t � �Tnoay C� 3a <br /> SAN JOAQUIN COUNTY ENVIRON" ENTAL HEALTH DEPARTMENT <br /> LTypeof <br /> N`` e�ERVICE EQUEST <br /> ness or Propert 1 FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> G ` 1 ( n CHECK If BILLING ADDRESS <br /> CA FACILITY NAME S 1 J\f�J <br /> SITE ADDRESS \�'}� ` i rl\��,/ p�t/1\ t�C� —�1 z✓ �/—}71� `1520 5 <br /> 1 Strer�et Njumber I Direction v V C Street�am\e\/ t v QJi '�`/ Zi Code <br /> HOME Or MAILING ADDRESS If Different from Site Address) <br /> Street Number LJ StreetTJa �� <br /> CITY __^ I STATE ZIP <br /> PHON 1 EXT. N# LAND USE APPLICATION# <br /> IT0 AP <br /> aj(� 1 - SSCP q I ll 21 i--I- <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) 00, l �Yk <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS N lC PI{ANE / _ EXT. <br /> .� fvl- <br /> HOME or MAILING ADDRE S FAX# <br /> CITY ST b ZIP cy <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 e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FED WS. <br /> APPLICANT'S SIGNATURE: DATE: S I <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ' ( <br /> COMMENTS: v� <br /> Ja S 2419 <br /> 'SRT 4 <br /> ACCEPTED BY: �/� :Cl n/1n/� � EMPLOYEE#: DATE: <br /> ASSIGNED TO: Af l V�1(J V L D EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (:52--3 P I E: 1 LVO <br /> Fee Amount: #?4 S — Amount Pai —6 OD Payment Date V/�J <br /> Payment Type Invoice# Check# 3b/9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />