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SAN JOAQUIWUNTY ENVIRONMENTAL HEALTH*I-RTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-LIds �6 v q- <br /> OWNER/OPERATOR <br /> c Lv— e eA1 Lo--V1 CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS 1��• �l�d��) 1 <br /> Street Number Direction Street Name city Zi Code <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 /> PHONE#2 ExT• BOS DISTRICT LOCATION <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S<"LCA Sta-tLc o C Syc'A vas, <br /> -TwC- /Yd r' ^'�_f �(tu CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 J 1 Yl+w ` (�J� Tj� PHONE ExT. <br /> Sery tt� i ti l S Sf`e� Sv'�c. T <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE (iut ZIP <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: {r s u L - �1,'.e Lti p t DATE: i f a6 G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13Cs(+i. <br /> OTHER AUTHORIZED AGENT M CL,,"&a I/C d 6(/;her <br /> If APPLICANT is not the Bram PARTY,proof of authorization to 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. 1 <br /> TYPE OF SERVICE REQUESTED: YC <br /> Gt`�I <br /> COMMENTS: p 'CXL�Q` `t V 1 �ZIJA+ 9 2 O <br /> JUN 2006 SAN JV(��tJiEN Al <br /> EN FPAR t�1EN� <br /> ENVIRQ 11FE—N i HEALTH NEg—j";D` <br /> T <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: /(/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount.Paid `j Payment Date Z� <br /> Payment Type `� invoice# Check# \'l L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />