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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 41 i l Sgoo (./) z 0(";`7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACIUTY NAME -fa4 w PCU <br /> SITE ADDRESS 3%-t(90 g m4CAA"� w TR.a U/ 9 5 37 (o <br /> Street Number Dimeaon tenet Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVeel Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 API# LAND USE APPLICATION# <br /> (Ze9 ) 6It1- &S8t <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> I ) 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> � � /2_ CNECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> T kA10Ce W67 1 -3& rtvsL <br /> HOME or MAILING ADDRESS FAX# <br /> //0 A) / cJ L,.,e« Ltl 60lc '57-3b (Zac, I -.$ & I6'13 <br /> CITY /ILLI~ STATE ZIP 9 5 2-LVO <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,STA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE• <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ZP OTHER AUTHORIZED AGENT 13 <br /> I,f�APPLICAAT is not the BILLING PARTY proof of authorization to sign is required Title <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: pAXMENT <br /> COMMENTS: RECEIV - <br /> gg - 4 2011 <br /> yJi JOAOVM COAL <br /> HEALTH'EEPAPTMES1 <br /> ACCEPTED BY: EMPLOYEE#: M�2 DATE: <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (N already completed): SERVICE CODE: P I D <br /> Fee Amount: 0 o Amount Paid 3 _ Payment Date 3 y <br /> Payment Type ✓ t 5 Invoice# Check# bel a 5 Received By: <br /> 46 a <br /> tip <br /> EHD 43-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 7, O� <br />