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A I • • <br /> SAN JOAQUOOUNTY ENVIRONMENTAL HEALTIAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2. '�- 5Q- <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> -A t4h <br /> SITE ADDRESS /5i37 37 " ] _�f n-Y / /) <br /> Street Number Direction ( // �(SJtreet Name 6� L it Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> `3 3-3 id - CQ ( ST- - Street Number Street Name <br /> CITY N- Isco � �V 4- ST;TE TSP O <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Q `^ O P—o t Z CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1�/^ RA- ,-�M PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 13-701 S • X41 <br /> CITY �'"rC4,RC STATE ZIP Q G2 <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: t�, DATE: & <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT SU Pc r✓IS e r <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. U _ST G ,F- I—r <br /> TYPE OF SERVICE REQUESTED: �'(Z P 1kAS'!57 117 U P Gt ra-(c <br /> COMMENTS: y _ ��,,p c.N' V Dg k4) S <br /> 3014 16 2008 <br /> SAN JOAo um Co t <br /> HATH pEPAR ME <br /> ACCEPTED BY: I fZ4 EMPLOYEE#: DATE: <br /> ASSIGNED TO: cl A'C ) t EMPLOYEE#: t L4 ZZ_ DATE: , 3 �l g <br /> Date Service Completed (if already completed): SERVICE CODE: C P/E: o <br /> Fee Amount: L ' 0-- Amount Paid TAY Y-,0 Payment Date <br /> Payment Type �/ Invoice# Check# 30-1 Received By: 7� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />