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SAN JOAQU COUNTY ENVIRONMENTAL HEALOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> D� Oe [���C 222 <br /> OWNER/OPERATOR �'qjf� Ma�csh <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ' <br /> SITE ADDRESS G�S� , I` 194�il(e <br /> SllVi n I SName1. ��C <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 /> ( ) M- I�d) 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ftC'-;eA- USG I� ' 1 I <br /> r CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> '1 q3 — 3Odp <br /> HOME or MAILING ADDRESS FAX# <br /> . 0 , Box 5 5 l 0 5 ( ) c143 - 3og <br /> CITY 5 <br /> -C) STATE CA ZIP 95r2Z <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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STA.Tf.and FEDERAL laws. �( <br /> APPLICANT'S SIGNATURE: �IhgtwDATE: <br /> �p <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> �fld <br /> If APPLICANT is not the BILLING PARTY.proof Of authorization t0 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: <br /> RECEIVED <br /> SEP a 3 201',] <br /> SAN JOAQUIN <br /> TM <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: V t EMPLOYEE M Q DATE: R t o <br /> ASSIGNED TO: �E ® EMPLOYEE#: ( L4 Z1 DATE: q 3 b o <br /> Date Service Completed (if already Completed): SERVICE CODE: ) -(� P 1 E:,-2_3,0 <br /> Fee Amount: 3lo&'1707 Amount Paid 1. Payment Date 9/3JI O <br /> Payment Type t/ Invoice# Check# I t 5 Received By: -- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />