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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> <4P- .521-,V 3 to Sr S y zCl -Z <br /> OWNER/OPERATOR <br /> �) CHECK if gl.LING ADDRESS <br /> FACILITY NAME <br /> SITE AD ESS / J� / �� Q / y g`�Q G <br /> Strout Number Direction !7 St ant,;Lc/ ACL�6�N JZI Corfn <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> StrooT Nutttbur fi[ t Nurnu <br /> CITY STATE zip <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> IFPS► 6�� Y SS/ <br /> PHONIw#2 EXT, BOS AISTRICT —77L0C7ATI(0)N C!71 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORef /ter!!-"G! <br /> CHECK IT BILLING ADDRE551..�1 <br /> BUSINESS NAME PHONE# EXT. <br /> HOmE or MAILING ADDRESS FAx# <br /> CITY KKI) <br /> STATE C zip -:9 </ <br /> Q✓1 �� Ci .jC� <br /> BILLING ACICNOWLEDGEMEN'll' 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVIRONMEN'TAt. HEAL-1-1-1 DLPARIMLNT hourly charges :associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 /> COUN-I-Y Ordinanee Codes,Stanclards, S']'A71.and Fi-,I)CRAL laws, <br /> APPLICANT'S SIGNATURE: DAT[: <br /> PROPERTY/BUSINESS OWNEROPERA 1-ort/NIANACER ❑ OTtlEltALIT110RIZEDAGLN'I']�O �r iia+-i m f, <br /> �,-1PPLlL'.aNT is n0/I&HILLING'PARTY,pragJ'oJ aulllwtlal�On to sign is required Title <br /> AUYNORIZA11ON TO RELEASE; 1NIFORIVIATION: 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 :Ind/or environmental/site assessment <br /> information to the SAN JOAQUIN CQUN I ENVIRONMENTAL HLALTH DEPARTMENT a5 Soon as it i5 available and at the sante tirne it is <br /> provided to nae or my representative. <br /> TYPE OF SERVICE REQUESTED, t , �- �� 1 �F� 6nv, <br /> COMMENTS: ' <br /> A y 200 <br /> h�CTH nEpA�0�N <br /> At <br /> ACCEPTED BY: / r- i EMPLOYEE#: DATE; <br /> Fii �:,� <br /> r✓ s 2 I -f7 C <br /> ASSIGNED TO: _ EMPLOYEE#[ OATE: S 7 <br /> Date Service Completed (if already completed): SERVICE CODE: I C P/E: <br /> Fee Amount: . a Amount Paid t� }� r Payment Date 5 19 I A S <br /> Payment Type Invoice# A, <br /> M� t�S 8I'�TL"# '� SS Received By: ,v <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br /> 90/80 39tld -nIH >ioIIH3 8ZS8868T99 ZT :ZZ 800Z/T0/S0 <br />