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` <br /> i SAN JOAQUIN �.JUNTY ENVIRONMENTAL HEALTH DL.. RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SAS s A-T-t l <br /> OWNER/OPERATOR /_ <br /> �� �,Q�\ CHECK if BILLING ADDRESS <br /> FACILITY NAME Lutc, ``Y1 1 J� ave / <br /> SITE ADDRESS ' ' � 4 �' <br /> JIQ lg� <br /> Street Numher Direction Street Name Cit Zi Code.; <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street N -,.t Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT- BOS DISTRICTLOCATION CODE <br /> ( 1 <br /> CONTRACTOR R ICE REQUESTOR <br /> REQUESTOR <br /> �T U CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 V C{ r'` f PHONE# EXT. <br /> ScrrV .c-e, S�-hc t.l S 5 -rox— , �t - 0 3 B <br /> HOME or MAILING ADDRESS FAX# <br /> � �0 QL`iVL(.1 V.e- (4!68) ala -(00,-;-)� <br /> CITY am- 1�� STATE /1 A ZIP Q 5-/ /,Q- <br /> BILLING ACKNOWLEDGEMENT: I, t e undersigned p/HEE <br /> ness owner, operator or authorized`agent of same, <br /> acknowledge that all site and/or proj t sp cific ENVIRONMENHEALPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my us' ss identified onI also certify that I have prepared this a ica nand that the rmed will be done in accordance with all SAN JoAQuIIa <br /> COUNTY Ordinance Codes,Standards,S A and FEDERAL laAPPLICANTIS.SIGNATUREs �t-�' .k.L DATkt <br /> PROPERTY/BusiNESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 10 Cep tLl Q,Lt(Q <br /> If APPI.ICA T is n he B/LuNG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO INFORMATION;When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby orize the release of Vy and all results, geotechnical data and/or environmental/site assessment <br /> information to thIlWe<JOAQUIN UNTY ENVIRON AL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or ilk r esentative. PAYIL�Ei\1T <br /> L TYPE OF SERVICE <br /> QQRSD ) -��Eo((� <br /> COMMENTS: � J�� V v• CJ� oL. 'lJ P �VJ�� (V�11�`Oti��O��Q� '\s \���� D <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL NOV 1 6 200 <br /> HEALTH DEPARTMENT <br /> ENVIRONMENT HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already mpleted): SERVICE CODE: // P i E: d <br /> Fee Amount: Amount Paid _ Payment Date dKx <br /> !l 7/D <br /> Payment Type nvoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />