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SAN JOAQUIN UNTY ENVIRONMENTAL HEALT EPARTMENT/ Nvllo <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6AI"M FILL -F 5jz-c�-o L4 !a 5-1 <br /> OWNER/OPERATOR <br /> l�vG©i2�oR�4 T CHECK If BILLING ADDRESS <br /> r-OR Lt/�b <br /> FACILITY NAME r-or- P-0 <br /> SITE ADDRESS G)G�G�9 S A-usFl,-,) 90A AA& T6�A- gs33� <br /> ff Street Number Direction Street Name Cityi 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 /> ( ) 0/0&00 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �( �� / ,q� � <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME (HQy n C� —7-777 EXT. <br /> HOME or MAILING ADDRESS / FAX# / <br /> l3� l/Avr Y C/�ST� �R i ( g0 301(o — l7ly v� <br /> CITY P/A"UNQ 9/k?Q 0?A-$TATE ZIP q j7&(J� <br /> v, J <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 or <br /> 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, ST an FEDERAL laws. /2 / <br /> APPLICANT'S SIGNATURE: v ( - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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: <br /> COMMENTS: , wv }p, jb F'qy <br /> EQ <br /> LJL L 2 0 2005 <br /> a't1 1010 L. AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> jF I HEALTH DEPARTM <br /> ACCEPTED BY: EMPLOYEE#: �3,Q�\ DATE: <br /> ASSIGNED TO: EMPLOYEE#: V 3�� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �V b P/E: <br /> Fee Amount: 1 <br /> 2 UA Amount Paid (1 o Payment Date <br /> Payment Type Invoice# Check# 5 a C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />