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•r v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 51200 81 <br /> OWNER/OPERATOR CHECK N BILUNG ADDRESS O <br /> MA !: a k v. 14-e- Y. <br /> FAcum NAME <br /> SITE ADDRESS 333 S I- ,cc I II <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sleet Number Street Name <br /> CITY STATE LP <br /> PHONE## EXT. API LAND USE APPLICATION K <br /> (209 ) ` &3- 2S77 183 - 3ZO - flPA-GiS- dSoCMs <br /> PHONE#2 FXT. BOS DISTRICT LOCATON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS 14 <br /> BUSINESS NAME Q PHONE# ExT. <br /> cUr 1L ZM 33¢ -66 <br /> HOME Or MAILING ADDRESS FAX# <br /> F.C. $DX ZI ( 709 ) 33+- D?Z3 <br /> CITY LOA; <br /> STATErA ZIP C:;,41 <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 as identified on this form. <br /> 1 also certify that I have prepared this a licalion and tha hew k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and F E L 1 11 <br /> APPLICANT'S SIGNATURE: DATE: 3 `4 - OS <br /> PROPERTY I BUSINESS OWNER 13 OPERATOR/MANAGER Id OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY 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: �L)��ac G JIJ� cS (-I-tACG T P "1vE <br /> COMMEWS: /f/'f IOS <br /> l�LdrT y�t/Cf3c1E7� '—V I I3ir0 ON <br /> �� <br /> ( (�e/5174;,1) 3a MEPP <br /> ACCEPTED BY: b L (�'E, y( EMPLOYEE#: C)S a DATE: 3 cE l p c <br /> ASSIGNED TO: E S C o-I-(v EMPLOYEE#: S','( DATE: 3 400. <br /> Date Service Completed (if already completed): SERVICE CODE: 3 15 P I E: <br /> Fee Amount: _ t fi. V Amount Paid p Payment Date 3 o S <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />