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SAN JOAQUIr JUNTY ENVIRONMENTAL HEALTH, 2ARTMENT 2 ® o 0 7 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# FACE REQUEST# <br /> n <br /> v1 <br /> OVAIER/OPERATOR <br /> IY25 . LA CHECX if BILLING ADDRESSu <br /> FACILITY NAME <br /> SITE ADDRESS 3 2 /SO �!(� GT. STty q�. 04 <br /> et er <br /> StreNumbDirection Street Name Cky <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number N <br /> CITY STATE zlP AN <br /> PHONE#1 Exr• APN# LAND USE APPucanoN# c D <br /> Vo ) -471, Mqr <br /> PHONE#2 Exr• BOS DISTRICT I�CA71ON C <br /> { ) lily <br /> CONTRACTOR/SERVICE REQUESTOR �r � '� <br /> REQUESTOR �/ <br /> D O l�fT S� CHECICif ADDRISSLI <br /> BUSINESS NAME PHONE# r <br /> eo/�ISGfL r <br /> 1,70foZ-& e�- <br /> HOME or MAI t;ADDRESS FAX# <br /> D- 7 { l <br /> CITY 2 L _ _ _ STATE /,? ^ ZIF <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorizeddJageent of same, <br /> aciclowledge that all site and/or project specific ENvIRONbfENTAL HEALTH DEPARTMENT hourly charges associated with t11is project <br /> or activity will be billed to me or my business as identified on this form_ <br /> I also certify that I have preparedthis a lication and that the Nvork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ATE and E61ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE-/_ 02 7 �D <br /> PROPERTY I BUSIIHESS OXWERO OPERATO 1 MANAGER ❑ OTHER AUTHORIZED AGENT 1L�1 <br /> If f PPLIcAA7 is not the BILLNG PaR77,proof of thorization 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 ENVIRONAIENfAL 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: s 4eONrA--n1^1 OA� PE✓ h/ <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSGGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P1 E: 03 <br /> Fee Amount -307 <br /> ( Amount P 36 (] Payment Date <br /> Payment Type�� Chec <br /> , Invoice# k# 3637 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />