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SAN JOAQIftOUNTY ENVIRONMENTAL HEALT&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SERV ►C ' `a oos Q? 2- <br /> OWNER/OPERATOR <br /> /L 4�A CHECK If BILLING ADDRESS <br /> FACILITTYjNAVME <br /> 2e STS c IJ <br /> SITE ADDRESS C C7 U /' P—y C L-U�j 5' C I/--ODI <br /> [reef umber Direction Street Name Cit Zi Code 1� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zo5) 13 0r7 ( i3 D _0_t2_ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L 6 r .!Ar$,L.( A_ CHECK If BILLING ADDRESS <br /> BUSILNAMEG�M- P—Ar�L n G GT/,Q t�'G 0 f� PHONE# ) EXT. <br /> Y 4�Z-�O(oC. <br /> HOME or MAILING ADDRESS FAX# <br /> I v!, 0 M / tf 6 eeT ( zK W, 4-1�Z- <br /> CITY P L CI)SAW-FO tJ STATE e p ZIP 1 IC t ' <br /> BILLING ACKNOWLEDGEMENT: 1, 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 I ws. <br /> APPLICANT'S SIGNATURE: - �L /�1�1X L� DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT U e-0 AiF t e A-C--(-0L--1 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. LIT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> COVN� <br /> AQUW L <br /> S0A ot* <br /> HED TH <br /> ACCEPTED BY: 0 Lf v e t 9A EMPLOYEE#: ID 3 Zf DATE: Z O <br /> ASSIGNED TO: A Ce--u--C EMPLOYEE#: 4(.103(l DATE: Z I ! <br /> Date Service Completed (if already Completed): SERVICE CODE: t 4 el P/E: 2-3 ®5 <br /> Fee Amount: 3[�5,� Amount Paid 4 S „ Payment Date a \ 1 D <br /> Payment Type Invoice# Check# LA Z 6 S Received By: VT1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />