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0 <br /> SAN JOAQU&OUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> N G W W E S I 7 t✓I iZ Q L E V wt moi.( C CHECK if BILLING ADDRESS <br /> FACILITY NAME /`��,r� ��� # / O 03 <br /> SITE ADDRESS lAJ > A,K ki E!Z 5 r- L 0 D ( 9 S z-q Z <br /> 6 3 ,+ Street Number Direction Street Name city ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) G Vl- <br /> / 913 ( Street Number Street Name <br /> CITY /N,C 2IM EA-r <br /> ^ O STATE ZIP <br /> r'c C Pt- g s-8 l Lf <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( 9t6 ) 4143 - 08'Y0 X55= 326--( V <br /> PHONE R EXT• BOS DISTRICT LOCATION 90DE <br /> ( ) C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � L� ^M !Y VL, WA,(— � CHECK if BILLING ADDRESS <br /> ED <br /> BUSINESS NAME ,t /A ` }�- 11L T-V-2 C c PHONE# Ems' <br /> 916 3�3 - /rsz <br /> HOME or MAILING ADDRESS FAX# <br /> o K toz (0116 )34-3 - /t- Z <br /> CITY S /t 2 .p cm F;,� STATE 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 applicati n and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STA nd F E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ipl ►�'� 2 �— <br /> IfAPPLICANT is not the BILLING PARTz 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. Lc s:-T- 4;- F 1 T <br /> TYPE OF SERVICE REQUESTED: r L " le le-V t l=w S P 1 1 ►{ RECEIVED <br /> COMMENTS: FCD 2 4 Z0o9 <br /> SAN CJOAQUIN COUNTY <br /> ENVDEPARTMENT <br /> NTAL <br /> HEALTHH <br /> ACCEPTED BY: Cit L L/�f t2-, EMPLOYEE#: 4!!: DATE: <br /> ASSIGNED TO: /y is( C A7-0 t r- EMPLOYEE#: ( ? '1-__ DATE: 7 <br /> Date Service Completed (if already completed): SERVICE CODE: c�k P 1 E: <br /> Fee Amount: -5 /5- L Z, Amount Paid r Payment Date <br /> Payment Type Invoice# Check# LA J J Ly Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />