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SAN JOAQUL-9-CouNTY ENVIRONMENTAL HEALTH rPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -rv-Ajt� aa(ifA, it,)P//TW k-1 0C. FA000385y 5,e eokl778 <br /> ONMER/OPERATOR �/// <br /> ry In C..G \_10 2,r \I DE 1 � � � CHECK 1f BILLING ADDRE55O <br /> FACILITY NAME U 67 W Ion F 11L 1e�G R-T <br /> SIfEADDRESS S 3 S G� P5SGA DE Q-0 QV E TTLA CGL'( <br /> Street Number Direcao reef Name C' Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number seg Name <br /> CITY STATE ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> S Il e-�jp J CS-1 CNECK if BILLING ADDRESSff <br /> BUSINESS NAME PH E Exr. <br /> �.»H �,�r9lvtE� rt� r-+tom 1 IN c. �S ,S�� SIICc <br /> HOME Or MAIDNG ADDRESS�`,�S I=EA AA L4, �2 <TE A - I S ) I ) <br /> CITY S,U rJ 136 R'J 4 AA nN FI,0 1 4-A STATE LP q 2t-1074 <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 asoidentified on this form. <br /> I also certify that I have prepared this applicant d that the work to be performed will be done in accordance with all SAN JoAQuIN <br /> COUNTY Ordinance Codes,Standards,STATE DERAL laws. I - <br /> APPLICANT'S SIGNATURE: DATE: t- LP - j <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT 1117 20�f 6 Q' pal A a 4&6 2 <br /> If APPLICANT is not the BILLING PAR proof of authorization to sign is required Title <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 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: s! 7;,ee II <br /> COMMENTS. DGMD CONrn.e-fc Apuvd o Aa NvvA rL I.IOO. &G4 /7L <br /> Ort, jo OYLOC2 To Frsl-I UWIL,Li <br /> NAJ6 QELDME 6N SRI/JL-C>�t?U/�IL. "� <br /> ACCEPTED BY: EMPLOYEE M �c/- DATE: / /Z/ZC/1 <br /> ASSIGNED TO: '�'t�-f EMPLOYEE#: f ( j DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: a 71 E:,�30� <br /> Fee Amount: J-Yr+�of Amount Paid �60c Payment Date Z <br /> Payment Type 1 S Invoice# Check# S a _ q( 34 S Vy Received By: <br /> EHD 48-02-025 4 9 b 3 - RRRIV 1WRod) <br /> REVISED 11/17/2003 366. 6v R 'N <br /> JAN 12 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />