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SAN JOAQtIN COLNTY ENVIRONITIENTAL fIEAI;rn DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n k0i QuA 75 -7 'XIX � 32S2— <br /> OWNER I <br /> ,OWNERI OPERATOR CHECK if BILLNG ADDRESS <br /> FAcirnY NAME {�'�(�L� `` '',,\\`\,, Q <br /> SITE ADDRESS "t(J � S l�Wl 9 { VtVMTu i lam^ ' �l <br /> Street Number Direction Street Name city zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Sheet Mrm6er Sheet Name <br /> CITY STATE Zip <br /> PHONE#1T' APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 EM BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ; CHECKif BILLING ADORES <br /> ILJ``\J r PHONE# 6cr. <br /> BUSINESS NAME _ /1ll \ (— <br /> HOME or MAILING ADDRESS - FAX# <br /> l)JIC�W'A� C X l <br /> CITY - STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> 1acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> ;'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,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNA'T'URE: �} L�C DATE: y+12� �n Z(),I) <br /> PROPERTY/BUSINESS OWNERO OPERATOR INIANAGER �.� OTuERAITCNORIZEDAcRNT❑ c`P�1rQ aP� 4 11.Q i <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required - <br /> AUTHORIZATION TO RELEAS19 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 enviromnental/site assessment <br /> -information to the SPIN 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. &YMENT <br /> p . <br /> TYPE OF SERVICE REQUESTED: vC.S T f-'c —r— RECEIVED <br /> CosmENrs: G +c� S c .4 DEC — 20 <br /> S N iOAQUN COUNTY <br /> E:JIYIRONMENTAL' <br /> HEALTH DtPART AL <br /> ACCEPTED BY: EMPLOYEE#: ,� DATE: I Z. <br /> ASSIGNED TO: i �.._ r-'-r+ EMPLOYEE#: r. L 'Z - DATE: . / 212-11 <br /> — 11e Service Completed (if already completed): � SERVICE CODE: �� �" PIE: Z.�0 <br /> Dat � <br /> Fee Amount: P 6 Z' Amount Paid C2 -7 S'0 , D Payment Date 1 L <br /> Payment Type 15 invoice# Check#-71) -7� Received By: -L-1-/L <br /> �cLo O37s) a 4 t'foi <br /> EHD 48-02-025 <br /> REVISED 11/17/2003. <br />