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i SAN JOAQUI1*OUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pr7`crop <br /> erty FACILITY ID# SERVICE REQUEST# <br /> q� or� JJs FA 000 3-73 1 <br /> OWNER/OPERATORI <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME P^& <br /> n r L/y <br /> SITE ADDRESS (/}t ����f �ti1n �� / o n 1 ��2(�/1 <br /> SStrleet Num er Direction Street Name �u l/ CiU Zi Code6 L— <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# L.AND USE APPLICATION# <br /> (Zeal ) 1(10D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( y C q6 ! r <br /> 1 J CHECK If BILLING ADDRESS El <br /> BUSINESS NAME S r tin Ser, v`I 0-' P ONE#) �t�D 0 EXT. <br /> 366t - <br /> HOME Or MAILING ADDRESS I I"' J l �,^ tCom/ (�v �Ax#�G) /�j _ �6 Sb <br /> CITY D b / (� V " �(J JTl v STATE Zn 1 vzip / S'0&/ 2— <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: DATE: <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: e 4-r© Y PAYMENT <br /> COMMENTS: <br /> DEC 312003 <br /> SANENVIRONMENTALUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: vbn � J EMPLOYEE#: Q?3/ DATE:/Z 0 <br /> ASSIGNED TO: C EMPLOYEE#: 113 6/J DATE: Z J b <br /> Date Service Completed (if already Complete .. SERVICE CODE: 1 1 PIE: Z3� <br /> Fee Amount: 2 7 q ro/V Amount Paid Z -7 e2,0-0 Payment Date 12,13110? <br /> Payment Type Invoice# Check# 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> I <br />