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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> 00 <br /> OWIM I OMATM <br /> EL/ - <br /> L_�-1UT, �„ C. CHECK it BILLING ADDRESS <br /> FAaurr NAME -- <br /> NCitl <br /> SITE ADDRESS <br /> J° til rJ' � y S`0A) !ovFT r>► l `� S 212 <br /> Svwt Numbor Nam* C Zip C I <br /> HOME or MIAMI ADDRESS (If Dl OMM from Site Address) ;--7 <br /> Strar�Numba• Struet N ms. <br /> CITY S TATE <br /> sTuL>-7 �oL:, ZIP 9Srz 2. <br /> PHONE#i n LANG USE APPLICATION 9 <br /> A t� <br /> ) 5z 09 _ <br /> �L <br /> PMONE i:2 EmaOS DISTRICT. <br /> ti` ` 71 LOCATK <br /> CONTRACTOR I SERVICE REQUESTOR 1 <br /> REQUESTOR Q t <br /> J4S s IP— CHEG(tf BILLING ADORESSS <br /> BUSINESS NAME PH —EXT. <br /> HOME or MAUNG ADDRESS _ FAY# ' <br /> I/l� L -'l0,�'-4r3�c1 LRS <br /> ( I <br /> CITY 5 70L STATE Z1P "� c, <br /> rA l <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and'or project specific ENVIRONMENTAL HEAL:1'H 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 JOAQUI", <br /> COUNTY Ordinance Codes,.Standar ,STATEand X�� <br /> APPLICANT'S SIGNATURE: ' D Zvi 9 <br /> A11:_ ^^ <br /> PROPERTY/BLSINIL%OWN ER�\ PERATOR/: ANAGER ❑ OTHER AUTHORIZEDACENT❑ JY! t � �� �� _ <br /> l!APPUc,gvf is not rhe�rc�!.nG PARTY,proof of authorization to sign is required rr�---i} rtrte <br /> AUTHORIZATION TO RELEASE. INFORMATION: When applicable, 1,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 JOAQU(N 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 /> �pfySERV'CE REQUE.S?EC,,: I ~.. t: <br /> PA 1 - i� <br /> RECN 67I AJC 5 �=�' n S I kn JF � <br /> NIS -NVIRONMENTAL HEAL1 H <br /> JIN Cout4v PERMIT/SERVICES <br /> JO TAL <br /> CiVVI, C'fR <br /> �EAl_T "k EMPLOYEE#: q DATE: I IP12 <br /> ASSIGNED TO: EMPLOYEE#; „ eJu 1T: j t <br /> Data Service Comp! ed (tf f (ty eo k►tod): U gcm 5-22 <br /> PIE. <br /> 2+2 <br /> Fee Amount: <br /> O l_�- Amount Pa 3 . ()0 Parnent Date IO <br /> Payment Type Invoice A Cheek ik !32 - Recel! By: <br /> EHD 48-02-025 <br /> REVISED 11117!2003 SR FORM(Golden Rod) <br />