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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> --TType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CNECKIf BILUNGADDItIESSIM <br /> FACILITY NAME <br /> C i i�d I . <br /> U � j � T1L �j -370 <br /> SITEADDRESS q 7J J r 1 / e/ O . '�I'�LI C <br /> / Shwt NumWr l e ow tNauw C 2 Ceds <br /> HOME Or MAIUNG ADDRESS (if Different from Site Address) <br /> Stmt NumO�r ma <br /> CITY STATE LP <br /> PHONE APN# LAND USE APPLICATION# <br /> 6207) 831- 56 5% <br /> PHONE#2 SOS DISTRICT '_OCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / /L'' �a CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> I' <br /> HOME or MAILING ADDRESS / FA%# ) / <br /> CITY' STATE ZIP �53 <br /> BILLING A IC40WLEDGEMENT: 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,STAT d EDERAL laws. <br /> APPLICANT'S SIGNATURE: — DATE: �� S <br /> PROPERTY/BUSINESS OWNER OPE ATOR/MANAGER ❑ OTRERATTTHORIZEDAGENT)4 PP-SF-CT /�tAA/AC7F(Z <br /> If APPLICANT is not the PPf e7Y proof of authorization to sign is required Ttrtr <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 environmentaUsite 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 REOUESmo: �I .�.� �v e SJ F!I I daete <br /> COMMENTS: uS��,��2-�F cT PAYMENT <br /> RECEIVED <br /> FEB 1 2005 <br /> SAN JOAQUIN OUNTY <br /> NTAL <br /> I POYEc : y 'DATE: DEPARTMENTAPPROVED BY: 3 <br /> ASSIGNED TO: .SNI EMPLOYEE#: 3 ev DAT`-: Z I 00 S <br /> Date Service C mpleted (if already completed): SERVICE CODE: 6 PIE: 7_3, 06 <br /> Fee Amount: - ;L:79,L, t) Amount Paio $379 C�l7 Payment Date '.. S1 Og <br /> Pavment Tvpe Invoice I Check# Received By: � <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-502 <br />