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SAN JOAQUI.. —'OUNTY ENVIRONMENTAL HEALT}_ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prrope FACILITY ID# SERVICE REQUEST# <br /> I)Wel /722 S' ip_ 00(,-lo2Z <br /> OWNER/OPERATOR / <br /> U J CHECK If BILLING ADDRESS <br /> FACILITY NAME NJ `1 / / 4,3 <br /> 2 i / <br /> SITE ADDRESS 1 <br /> `(J 7 t� \Jl./ <br /> "J �d Gk f 9 5 p21 <br /> t!va� � f�en�� Ca fi� 7arn�i�e l�. <br /> / <br /> Street Number Direction Street ame Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT* APN# LAND USE APPLICATION# <br /> 6)oq ) 4107 C> <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> L CHECK If BILLING ADDRESS <br /> BUSINESS NAME / )� ��� 1� G PHONE 1?-7.31— <br /> ?-7.31— EXT. <br /> HOME or MAILING ADDRESS /� Vne // D `P` FAx P— I-) lv <br /> CITY San o5e- STATE/�(/ ` 7ziip .l l <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: 7 L) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tale <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 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. �\ �pLC;e SI��F// �e4E Wt C>J 6 C— ,OL-A,' C'�-4 CCe- <br /> TYPE OF SERVICE REQUESTED: f U (/ (�l L/6 `1 Q n L e N 1 <br /> RECENE <br /> SEP <br /> p g Zow <br /> SAW RONIME COUNTY A <br /> T ENT <br /> ACCEPTED BY: `Cj i L/E f /I EMPLOYEE#: '�Z_� ATE: 9 <br /> ASSIGNED TO: G✓' � ZK� EMPLOYEE#: �2_f� / DATE: [ 7 �� <br /> Date Service Completed (if already completed): SERVICE CODE: 5'1P a <br /> Fee Amount: L`� �� ) Amount Paid 'a y q Payment Date c� D`D <br /> 7 ' <br /> Payment Type `/ Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />