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DATE: <br />OTHER AUTHORIZED AGENT <br />SAN JOAQL COUNTY ENVIRONMENTAL HEALT1 EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />.n 7 <br />SERVICE REQUEST # <br />c".•,1‘ <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME FKitire_. n <br />SITE ADDRESS if <br />rdet Nu , 'ff': DbLon —roc_ Street Name <br />----( 4 z z <br />f V eY, 953Qq <br />HOME or MAILING DURESS (If Different from Site Address) <br />30 AA_.(2 Street Number Street Name <br />Crry STATE ZIP <br />( <br />PHANI <br />' ) 83 0 450 D <br /> EXT. APN # <br />- , <br />LAND USE APPLICATION # <br />PHONE #2 Exr. BOS DISTRICT <br />,,, , :L..) <br />LOCATION CODE <br />- I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />fyi-, <br />7 \\,i-c_ic,i4 CHECK if BILLING ADDRESS " <br />BUSINESS NAME)-14ye5 a f,, ik PHONE # . EXT <br />0 (35--8H 3 1) <br />DRRES3 ?A-- , HOME or MAle _ <br />(,) c__,L) .k ( GA 1(1_ci- (2`C-- <br />V Fax # <br />(Aq) 5 q 5-- 4-r8 <br />crry , <br />r-: ILO n7\ <br />STATELF, <br />ZIP 9; <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site ancUor 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 id) be performed will e done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDERAL laws. <br />I <br />C,riffraCt 0( <br />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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anjit the same time it is <br />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: PCTX) I (2 ( a/v-1 (f, _•4 <br />7 COMMENTS: JAN <br />4 it <br />siliv ja4 <br />ENvinQuiN co ilEAtrti ()WAIT L'IvrY <br />E'EPAR,-,,,AL <br />ACCEPTED BY: <br />11A - NIA-to 1 <br />EMPLOYEE #: L .1 (.,, DATE: ( / / 4 i ( cf. <br />, <br />ASSIGNED TO:; , f ..:. ' <br />#: I ,f 7 ,,, , DATE: <br />Date Service Completed (if already completed): SERVICE CODE: — <br />2 '` / e_ P 1 E: <br />Fee Amount: 4 7c-i) •__. Amount Pai ) i , ) Payment Date <br />Payment Type / Invoice # Check # 7 ', Received By: r i <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPE T R / MANAGER 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require <br />4411 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003