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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTH-T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /�(slCY T L EC- <br /> OWNER <br /> C OWNER/OPERATOR CHECK If BILLING ADDRESS O <br /> I�MRt k � N H P C <br /> FACILRY NAME R <br /> SITE ADDRESS +Kjr W If b7 CA '75376 <br /> Ok Street Number Direction Street Name /C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY - STATE ZIP <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION# <br /> (�Pa1> S3D,- hO3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> EXT. <br /> BUSINESS NAME T / T P E /} '7 t—_(�'(— <br /> HOME or MAILING AD/DRESS / / FAx#_ <br /> CITY � _C STATE (�O ZIP 96-3 -7 <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 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, STAT and FE <br /> DERAL law's.' <br /> )CAPPLICANT'S SIGNATUIItRpLE: �; lr /��l t DATE: Io2 — a a —0-.3 <br /> PROPERTY/BUSINESS OWNERP. OPERATORiN/,,A'NA—GER ❑ OTHER AUTHORIZED AGENT 11IfAPPLfcANT is not the BILLING PA2TI'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: /UX U_LT—A_70 A1) -- /l W OWAC—_� PAYMENT <br /> COMMENTS: <br /> DEC 2 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: SLI v$t EMPLOYEE#: d 3 Z DATE: I�Z(03 <br /> ASSIGNED TO: .��og P_CC,14 LL 72— EMPLOYEE#: ,33(0 / DATE: �03 <br /> Date Service Completed (if already completed): SERVICE CODE: C)(Q/ PIE: I&. ,pL <br /> Fee Amount: C)"3,.pv Amount.Paid Payment Date /;z <br /> Payment Type �. Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rol) <br /> - _ <br /> - REVISED 11/17/2003 - " <br />