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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH 91PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G A-S 'Sc ATIO tst -('.o -G"v Q "72 _Skoo y �, S b f <br /> OWNER/OPERATOR ^ <br /> V�(, r� " CHECK If BILLING ADDRESS <br /> FACILITY NAME i �CqeLJ. e.r <br /> SITE ADDRESS <br /> Street Number Direction l Street Name , 1\ cityZio 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 /> � ) <br /> Oil 1 . <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE lsOR .tLC� SE -�Ccy1 � `� �a �` W��mtuA \ CHECK If BILLING ADDRESS® <br /> J TC N/`� PHONE 1 EXT. <br /> BUSINESS NAME C`��n r C S p S � � c 3_463Y 4 6 3 Or <br /> HOME or MAI)IN ADDRESS C(� FAX# 0 <br /> (0c Quvx vt (41b&) 943— (6 O Q(p <br /> CITY S 0.L&- A C s STATE 0&- <br /> ZIP Q 11Q/ <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: <br /> DATE. . <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ut LL�a!&k <br /> If APPL/CANT is not the BILLING 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. 11 <br /> TYPE OF SERVICE REQUESTED: �,� / 1 1�p p c <br /> COMMENTS: II"QC_�Ct A 'T(� iot51tLUo�t(an �0� rJellSCl� T <br /> cM. 4���.l lf.�-Qv T&--1,4-- �c C'uA—L `�) v� �r� 1`c &0` � Uv t C VES <br /> ;.ANY <br /> ACCEPTED BY: /�""-I EMPLOYEE#: DATE: N 30UIN 14TAL <br /> V" P�1 S Z�—O NVI pEPARTM M <br /> ASSIGNED TO: EMPLOYEE#: f S 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C p/E: <br /> Fee Amount: C) ✓ Amount Paid r Payment Date 5 Z L D !o <br /> Payment Type C Invoice# Check# I ZUf�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />