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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTifEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -Va �- 2c) <br /> OWNER/ OPERATO� <br /> Y*,- <br /> � D O ` CHECK If BILLING ADDRESS <br /> C. <br /> FACILITY NAME Q ` \ <br /> SITE ADDRESS 3 Z L�� \A G YY� t1n �' lea tom_ �L C Imo ` ►1 lciS,20`1Street Number Direction Street Name Cit <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i b / - Street Number Street Name <br /> CITY n ► STATE -z— ZIP �SO <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 1 <br /> Q000 S -? - D <br /> Pq9jW 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE RE' QUESTOR <br /> REQUESTOR ���/� <br /> CHECK If BILLING ADDRESS pal <br /> BUSINESS NAME ,C ' F w [ J P ONE# Exr./ <br /> V �Q Y (�CcL�C�rS GC. '-A61 _ L- <br /> HOME or MAILING ADDRESS FAX# <br /> i <br /> 'Ci ) a I - 63`1 <br /> CITY STATE ( ZIP `, --- <br /> L' 1 <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 HEALTI-I 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,Slandal•ds, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �, DATE: 2 <br /> PROPERTY/BUSINESS OWNFR❑ OPERATOR/MANAGER ❑ OTIIER T AUTHORIZED AGEN �/ ��'V� <br /> If APPLICANT is of lie!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: <br /> COMMENTS: RECEIVED <br /> NOV 2 4 2003 <br /> J <br /> SAN JOAQUIN COUNTY <br /> J ENVIRONMENTAL <br /> Y: g������ EMPLOYEE#: �c3� DATE: O.� <br /> ASSIGNED TO: dF EMPLOYEE#: DATE: - <br /> Date Service Completed (if already completed): SERVICE CODE: n<� P i E: <br /> Fee Amount: �.� Amount Paid Payment Date 1!/.,, �3 <br /> Payment Type Invoice # Check# ga Received By: <br /> EHD 48-01-025 SERVICE REQUEST F <br /> U�yZ <br /> REVISED 6-5-02 <br />