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c,t <br /> SAN.JOAQUIN COIJNTV ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T pe of Business or Property FACILITY ID p ERVICE REQUEST# <br /> I eS}� -E- ODZ2 3b3 '39, 2 <br /> OWNER/OPERATOR <br /> ( V� CHECK It BILLING ADORF.SS <br /> FACT NAM C—jam' <br /> ` ri <br /> SITE ADDRESS <br /> 2Z reeumpar , S?AT <br /> HOME or MAILING ADDRESS(If Different I—Site Adtlreee) <br /> Start N VTlln <br /> CITY <br /> STATE ZIP <br /> PHONE K1 E., APN p <br /> 2004 s'y ! LANG USE APPLICATION <br /> .. � �-y, b <br /> 1 PHONE N2 Ear. BOS DISTRICT I LOCATION CODE <br /> ( 1 <br /> " CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> �T a CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> t PNONE A ERr. <br /> t ' S '-1�t S <br /> HOME or MAILING ADDRESS FAX# <br /> S ( l <br /> CIN STATE, ZIP <br /> vl_.. BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner.Operator or authorizedagentof same, <br /> acknowledge that all site and'or project specific E\VIRONNIENTAL 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 /> COI;\7Y"Ordinance Codes,Standards.STATE and FEDERAL laws. !, <br /> � L f <br /> APPLICANT'S SIGNATOR DATE: OL1' I 2 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGE OTHER AUTHORIZED AGENT 11 <br /> If APPL/C.4,vT is not the BILL/NG PART);Proojojauthorization to sign is required rine <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 andlor environmental/site assessment <br /> infomlalion to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is A; <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED; � n ♦ /�/�� <br /> ;ED <br /> \ ��'� <br /> du�v�e�rs lam` q APR ?5 2 <br /> G��I��C � � F CoA 024 <br /> O N�/R QUI <br /> t I EMPLOYEE M DATE: 2 Zy ACTMEAN'�y <br /> EMPLOYEE#: DATE: ✓ 7/! NT <br /> Date Service Comp ted (if already completed): SERVICE CODE: rl 61 <br /> P1 E: , <br /> Fee Amount: 62— Amount Paid 1�2�oD Payment Date — Z <br /> Payment Type Invoice# Check p gD Received By: <br /> EHO48-02-025 v <br /> REVISED 1 111 712 00 3 SR FORM(Golden Rod) <br />