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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Pp X515 2 B F <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �► 0 oDg � <br /> OWNER/OPERATOR <br /> S I (`C• CHECK If BILLING ADDRESS <br /> FACILITY NAME r `� <br /> SITE ADDRESS W ,��— <br /> 45 Street Number Direction V Street Name I L(� Z�cq. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number V11AY Street Nam. <br /> CITY MT <br /> TE ZIP Lf^5i/2� <br /> PHONE#t Ex. APN# LAND USE APPLICATION# <br /> (707) &41-,o6cl2 <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> (5io, 241 -929f1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> IVD CHECK if BILLING ADDRESS 0- <br /> BU ESS NAMEI PHONE# EXT, <br /> S M)7 ) 11)41-&4-12- <br /> Hr rMAI INGADDRESS FAX# <br /> Lim ff�qa Kilo V ( ) <br /> CITY STATE zip <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: , DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIoRtzED AGENT 13 <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 enviromnentaUsite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sayye time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: WorlCF <br /> COMMENTS: <br /> �� // (}� APR 1 <br /> C" of OWILff Shp '" 0AQU/N 10 � <br /> M ,�MD�MECOA( <br /> ACCEPTED BY: /JI EMPLOYEE#: DATE: <br /> ASSIGNEDTO: V 1 EMPLOYEEM 3/��QI DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ;0; <br /> Fee Amount: U 71 Amount Paid 5i Payment Date 1 I Z <br /> Payment Type Invoice# '?J 5 22 Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />