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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6404)Co 13-4 gr <br /> OWNER 1 OPERATOR 30SEt' N 2 CHECK if BILLING ADDRESSO <br /> �E� <br /> FACILITY NAME E-C.EIZ <br /> SITE ADDRESS, 7gt <br /> EH <br /> Lc° -E�.{ .s #hSC-P"A-# Qd q S z-Z-o <br /> Street Number DirectionStree Name G ZI CoHOME Or MAILING ADDRESS (If Different from ! ��'� t P l_"T1 E(Z-Wb <br /> Street Number Street Name <br /> CITYNC M(%&P o STATE ZIP C-101 <br /> PHONE <br /> rj ZZ© <br /> PHONE#1 Exr. APN# 003- %30 —o 1 A- LAND USE APPLICATION# <br /> 4S-2-- 445 1 &0� tq-2— <br /> PHONE <br /> PHONE#2 ExT. BOS DISTRICT LOCA'noNI CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR D l� F CHECK if BILLING ADDRESS <br /> BUSINESS NAME: PHONE# k ExT. <br /> HOME Or MAILING ADDRESS � � r` FAx# <br /> (Serb *i99 - <br /> o� W ol�f <br /> CITY �,h� STATE C' zip q S a <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 1 have prepared this application and that the work to be performed will be done in alccordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT n FED laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BusiNEss OWNER❑ "A TOR' <br /> /MANAGER OTHER AUTHORIZED AGENT V4 VA <br /> If APPLIcRNT is not the BILGING PAR proof of authorization to sign is required j Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Iocated 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 nip or my representative. 09. <br /> -1 <br /> Nt TYPEoFSERViCEREQUESTED: \� SOIL SJltri��L1T� STCJ101, <br /> Uw <br /> COMMENTS: <br /> �la� t�c�.t f Po��tJ�r�Etsc <br /> ACCEPTED BY: r [ EMPLOYEE#: Q 3 DATE: �-6 27 t <br /> ASSIGNED TO: S LO 1 EMPLOYEE#: '5-e'q DATE. raj 4? 7�l (/ <br /> Date Service Completed (if already completed): SERVICE CODE: fir'Z y P f E: <br /> Fee Amount: �c�C�, 6-D Amount Paid a 4 l Payment Date ` 2 9 1 ) <br /> Payment Type ✓ Invoice# Check# 2 2_ Received By: <br /> END 48-02-425 SR FORM(Golden Rod) <br /> REVISED 91/1712003 <br /> F <br />