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SAN JOAQL_., COUNTY ENVIRONMENTAL HEALTIREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 52006P 7$ <br /> WNERI OPE O_9- CHECK If BILLING ADDRESS <br /> )n r � � <br /> FAcUr �Y' <br /> Y NAME I C) I1()(-1(1()(-1 � I'eo X- IN "U C- -fin <br /> SITE ADDRESS ` ' OG� <br /> 1 I Street Number Dimon `'pt0('11 Sieet Name Cit Zi Cotle <br /> HOME AILING ADDRESS tIf D'ffSite Address) Wco d ('ewy, <br /> OD.� . <br /> c- l••ll' rent from Street Number Slree Name <br /> CITY eb V(/(cticl C) STATE � ZIP /± <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# v, <br /> (am) y3c� - �� �G -- / z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 1 00 / Ol <br /> CONTWTOR/ SERVICE REQUESTOR <br /> REQUESTOR V /^W' —/T-)CM` )- <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAMEI r PHONE# , 'I EXT, <br /> HOME OJJVIAILING D SS J FAX# 1..� <br /> CITY CV /i STATE ZIP �. <br /> BILLING ACKNOWLEDG MENT: 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 farm. <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 a d FEDERAL' WS <br /> V <br /> APPLICANT'S SIGNATURE: v O DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPL/CANT is not the BILLING PAR TT proof of authorization to sign is required Tote <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&od � <br /> R F <br /> COMMENTS: ✓ryN ` Fn <br /> 84 JPA 9 ?p/4 <br /> yNQgQ'UiN Co <br /> NOFPggNTq�NT1' <br /> �7t1 <br /> ACCEPTED BY: tV'/r EMPLOYEE#: Zh2 DATE: <br /> ASSIGNED TO: �I� � EMPLOYEE M DATE: �I <br /> Date Service Completed (if already completed): SERVICE CODE: Q 6 P/E: <br /> Fee Amount: q1zs I Amount Paid /a5 OD Payment Date <br /> Payment Type Invoice# Check# Reaeiveb By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ' <br />