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SAN JOAQU --OUNTV ENVIRONMENTAL HEALT_ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5)2z"C (03/SU <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> /,) ZX /GJ, L iu j sr�� W Tv.l <br /> SITE ADDRESS <br /> / M? Street Number Direct on Street Name /T3 3 <br /> 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 EXT. APN# LAND USE APPLICATION# <br /> (2 0� > 3 �3 - Z;Lou <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR c- n�� ❑ <br /> x ILK J f CHECK if BILLING ADDRESS <br /> BUSINESS NAMESA-'n'E ��jG� PHONE# ExT,HOME or MAILING ADDRESS FAX# <br /> CITY L�— STANc w ZIP 'YS34_�L <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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 /> 0)tINTY Urc/incrnce C'odcs,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE — DATE: <br /> llimi,F:RIN /Rt'sim:ss0%%Ni.:R❑ OPER,\'rOR/MAN:1cF:R ❑ O'rI1F:RAt:"I'FlORV".f:DAGEVT❑ <br /> 1 Ai7'l.lc -INT is not the BILLING PARTY,proof g1'aulhorizalion to sign is required Tule <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> /jey- 14349 1e f fi(%-+ TIG i 7a71- 1.)r47n 4oWKJ 12AG1/1�/?O.� <br /> P�rnl';� <br /> RECEi J D <br /> AUG - 1, 011 <br /> _ N OUALTM <br /> ACCEPTED BY: EMPLOYEE#: �� DATE: t� ENVIRON P ENT <br /> �L <br /> ASSIGNED TO: PC7_-)12-14Z,9- EMPLOYEE#: (p Z t 3 DATE: �_ e/ <br /> Date Service Completed (if already completed): SERVICE CODE: ��y� P/E:3 bOZ <br /> Fee Amount: �S� Amount Paid (� O a Payment Date i-t( <br /> Payment Type Invoice# Check# C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />