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SAN JOAQUIN IWNTY ENviRONMENTAL HEALTH DLORTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (,AS 5-C&TL' A 72- <br /> OWNER/ <br /> 2-OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 S61 N �-3.- L Tolk-p- �L?a <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT-7 APN# LAND USE APPLICATION# <br /> QSI) 2-24"- It 0.- 17 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) S L C ! <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I 1 ,L+[ W� � CHECK if BILLING ADDRESS El <br /> BUSINESS NAME J l •S ` w `t V, PHONE# EXT. <br /> HOME Or MAILING AD,PR�SS FAX# <br /> (,Quv mi ) <br /> CITY S'a A -,J d% STATE 64 <br /> ZIP S I' <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:SIGNATUREc lit Gvx.�L G<✓ �'•�I� t �t-�L Zt��� DATi:. /1-Q. . a.� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 14 6M.P L Iii ia-e <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: (� �(�( �\/f'T Q Q �) Q �� + <br /> COMMENTS: i�'� e�CC�li1J�` �l d' D TTt� EIVE D <br /> DEC 08206 <br /> SAN JOAQUIN CO JNTY <br /> L <br /> ACCEPTED BY: G L( v t EMPLOYEE#: Q DATE: / � ART ENT <br /> ASSIGNED TO: A,,A EMPLOYEE#: 107 fJ DATE: f Z_ <br /> Date Service Completed (if already completed): SERVICE CODE: %�•E'0" P/E: <br /> Fee Amount: ''go1-1 <br /> ,�*t� Amount Paid ��$S Payment Date ' g p <br /> Payment Type Invoice# Check# R�Z Received By: <br /> EHD 48-02-025 SR FORM(Golden o ,7 <br /> REVISED 11/17/2003 ��� <br />