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SAN JOAQ*COUNTY ENVIRONMENTAL HEALT&PARTMENT <br /> SERVICE REQUEST <br /> T of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IF <br /> 3 � <br /> OWNER/OF_----- <br /> U 5 jq R-46 l Q Lt rh �r , r(� j o h CHECK if BiLuNG ADDRESS <br /> F IrIY SME Gas # �s <br /> SITE AooREss (7� <br /> LJ� <br /> lsv e 12►rQ n L4 n e �, i `7 s a (� <br /> ' Street Number Direction Street Name cft zip Code <br /> HOME or 1A mur-ADDRESS (If Different from Site Address) <br /> C�neS� <br /> {T� / Street Number n n Street Name <br /> C STATE <br /> PHONE#1 En, APN# LAND USE APPLICATION# <br /> (TC ) 91-4- gJC0 <br /> PHONE 82 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BING ADO <br /> end- c-, r� W <br /> B"mEss NVQ Em- <br /> le u rr, Cor(��a� i n PHONE# <br /> HOME or MAILING AD SS FAX# <br /> �303`�1 K1. r Qc—er— WaS 4S%6�S- �-- +{9 <br /> CRY nF0(- I STATE ZIP n <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 limn. <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 Codev,Standardv,STATE and ,.�FEDERAL laws. <br /> RE I p <br /> APPLICANT'S SIGNATUDATE: <br /> PROPERTY/BUSINESS OWNERp OPERA /MANAGER ❑ OTHER AUTHORUXI)AGENT❑ <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign iv required Title <br /> AUTHORIZATION TO RELEASE INFO LIMON: 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COWM NM: PAYMENT <br /> RECEIVED <br /> V APR 13 2005 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: 12, <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already c ): SERVICE CODE: PIE: ? <br /> Fee Amount:,, -7 Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# lir' �• Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />