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SAN JOAQU0OUNTY ENVIRONMENTAL HEALTHWARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINkss NAME <br />'T.J %- C1t_ <br />SERVICE REQUEST # <br />7Ph0+1A.1 CdMIPO.Il <br />ExT. <br />— L O g O <br />301s7 <br />_S4-©® 6700 "7t <br />OWNER / OPERATOR }.�1 <br />} .L.—�ia.�\ � �-�-�+L �O --a, cc� <br />`_ T <br />CHECK if BILLING ADDRESS <br />FacNAS` <br />P-7 1 Z <br />OIL <br />SITEADDRESSVN)G�sZ�� <br />treat Number <br />i tion <br />ame <br />i <br />Zi Cod <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />3 prgj S. O O Street Number <br />t <br />CI <br />STATE ZIP <br />Z - <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(2\y ) yLo`A - 'LS 3Z <br />0f3— <br />,U33 -c)/ <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />11 <br />LOCATION CODE <br />2— <br />CONTRACTOR / SERVICE REQUESTO <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINkss NAME <br />'T.J %- C1t_ <br />PHONE # <br />O l(o <br />ExT. <br />— L O g O <br />HOME Or MAILING ADDRESS <br />FAX # <br />CITv G� O � O ,J� <br />CS ATE1-4t- <br />P-7 1 Z <br />OIL <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 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 laws. <br />APPLICANT'S SIGNATURE: �y`j,�Q DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT � <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tette <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: tis T 4& -r,0 -Z 4:- t -PAYM F-7 ( �� <br />,. <br />COMMENTS: <br />Hurn+ cO"rm <br />SAS HEALTH <br />" TMD <br />PERM IT/SERVIGES <br />ACCEPTED BY: OL t v e ( L0— EMPLOYEE #: 3 Z DATE: <br />ASSIGNED TO: �n G�� I T- EMPLOYEE #: 1422- DATE: <br />s Z iv <br />Date Service Completed (if already completed): SERVICE CODE: J Ct Oy PIE: 2 3&e <br />Fee Amount: S_ N Amount Paid `� 3 �S !7 Payment Date s <br />Payment Type ✓ Invoice # Check # Lt1 Iq Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />V <br />