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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTOPARTMENT <br /> SERVICE REQUEST <br /> T of Business or Property FACILITY ID# SERVICE REQUEST# <br /> iL�U;A-121a� S Z <br /> CANNER/OPERATOkZ <br /> ( -^ CHECK If BILUNG ADDRESSLU <br /> FACILITY NAME ( �`]1'f l �� 1 3 �(�J <br /> SITE AooREss ��-+.�I v �] <br /> sow"Number Direction Stoat Name y Coda <br /> HOME or Mmw Aomss (If Different from Site Address) y� <br /> j� I C)I Street Numberlod c��ra 1Stmet Name <br /> C nt'"T CJy►{�l h-} IIS STATE ZPPJ 3 , <br /> PHONE#f ExT APN# LAND USE APPLICATION# <br /> 1 ^y 5 130 <br /> PNONE#2 ExT. BOS DmnucT LOCATION CODE <br /> ( <br /> CONTRACTOR! SERVICE REQUEST®R <br /> REflUESTOR <br /> 4-,- CHECK if BILLING ADDRESS <br /> En. <br /> BtASMI Ess '4r6 urn t i O n P55q Sg5 S <br /> HMAILNG ADDRES FAx# <br /> 18 6a F�ronSI ) <br /> CRY Ho pl r,r� STATE _) ZIP 9 30 -3.\ <br /> IN <br /> BILLG A1CtKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DFPARTMEtiT 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 1OAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE:S(" � },L�J DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AmtmzED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorizatdon 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. Lk s—r F (� I_ <br /> TYPE OF SERVICE REou e .I Tt S 1'3"+L E—U R r`CO•S `/ <br /> COIM em: 4 <br /> N4 <br /> SAN JOA ONMSNum T T <br /> ACCEPTED BY: U L t E(N/! EMPLOYEE#: C 3 2_I DATE: tklA <br /> ASSIGNED TO: C .l•-r—A U C% EMPLOYEE#: r, -3s'/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , `C P/E: 3. <br /> Fee Amount: ,�; Amount Paid �, (� Payment Date / D <br /> Payment Type Invoice# Check# 3 Received BY <br /> EHD 48-02-025 SR FORM(Golden Rod)101 <br /> REVISED 11/17/2003 <br />