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.. SAN JOAQUI OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> ' REQUEST <br /> Q <br /> " SERVICE RE y, lb <br /> � <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L AOJbFILL p <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f Y f <br /> SITE ADDRESS c)990v � �S S 111JQ <br /> Street Nu✓tuber Direction Street Name Ci Zi 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 /> 201 M021 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO��NCODE <br /> ( ) of <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEt3P ASSOCi 12'—Te <br /> PHONE#) � TM <br /> { <br /> V wI EXT. <br /> so <br /> HOME or MAILING ADDRESS f t � •� vis M 11 /G AX# 00 <br /> pJ <br /> O) -Q` _ <br /> CITY kJl` TE tz11P (4 17 <br /> U <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 don accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDERAL laws. C�Fs��^ 6" <br /> APPLICANT'S SIGNATURE: V l - DATE: 1 u <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: /6/3/�S <br /> Lo �S u5�. 2 �t•r Il rattiS SAN 30P( etAlp"- <br /> f <br /> E`�RpEPAPSM <br /> ACCEPTED BY: Q C..� EMPLOYEE#: /i�^3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: .3q-73 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P) OQ <br /> Fee Amount: ��,�� Amount Paid 79 Payment I—ep <br /> V <br /> Payment Type Invoice# Check# ...<< =7 Received By: ��� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />