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SAN joAQUIN COUNTY ENVIRoNMENTAL HEALTH liEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY I[} # SERVICE REQUEST # <br />OVYNER I OPERATOR CHECK if BILUN� ADOREWEI <br />FACILITY NAME + � <br />St 1S?�z <br />Srr AonREss N n Sa-a� l til Sl- � n <br />Name Cade <br />Streei I Sion <br />HOME or MAILING ADDRESS titDWgrentfrom Site Address), <br />TE ZIp 94583 <br />Cmt sa" <br />PHONE #i Ex''• APN # TLAND UsE APPLICATION12141 464'.55� 1394-f4o-01 <br />PHONE#2T OS Dt5STRiCT LOCATION CODE <br />t ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORCHa x 1f flaLUNG <br />A <br />akri Br-' 'l 6 t - PHONE# / Exr. <br />BUSINESS NAME � ta&n%� r fC t d (. Y� . t 'i# 1 5- 1% <br />Fax <br />ROME Or MAILING ADDRESS Z� G 1 5 - ( � `t�f 0 <br />13 P N • !"( c'Pk` tri , <br />CITY P� Ian,\ STATE ZIP 9+C �t <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, ST 'TE an laws. <br />APPLICANT'S SIGNATURE: DATE: _04- /-66/210 C <br />PROPERTY/BUSDwSSO"IZR❑ OPERATOR/ MANAGER ❑ OTBERAUTHORSZEDA6E T P' Title - <br />IfAppL1cAxT is not the BI LrNGP.�e7a. proof of authorization to sign is required <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 ENvIRONMbNTAL 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 />EMPLOYEE #: DATE: f� f <br />ACCEPTED BY: <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />SERVICE CODE: / p� P i E: <br />Date Service Completed (if already compietad): ! f <br />Fee Amount: <br />Amount Paid Payment Date <br />Payment Type <br />Invoice # Check # Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />