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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTI `EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# :::E�ERVICE REQUEST# <br /> RAS/DENT!/�L FALLO(i7l CaJ EIS <br /> OWNER/ PERATOR <br /> R� K O P4A11 ^ CHECK If BILLING ADDRESS <br /> FACILITY NAME /T <br /> SITE ADDRESS �ZKII T7- 1//NQ EA/ 9f-a3G <br /> Zt9 Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE - ZIP <br /> PHONE#1 EXT. APN# LAND USE APP (CATION# <br /> 19251 SZ0 az�v 09 - 030 �✓� 'Z"J -ay-e, s L-ls <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O CHECK If BILLING ADDRESS <br /> BUSINESS NAME G PHONE# EXT' <br /> C�fESn/� C'oN u� <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY R L O l Y� STATE /+^ ZIP S / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, opCe—raattoor 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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STtTk and AEDaws. <br /> APPLICANT'S SIGNATURE: I&Ikh DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ X,HER AUTHORIZED AGENT ICI <br /> IfAPPLICANT 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 REOUESTED: S/,(lzi-AcE Su Ss6eP-F.4 ca e4w,-4 m mo*rl oil <br /> COMMENTS: <br /> Z- -epl/ 3 a°D 3 2pp4 <br /> A�i7/7a/u�2�j 8 <br /> /h `f��ano ° Y1 FF UNGQVNTY <br /> SPENjHOOEPPp MENT <br /> ACCEPTEDBY: LI UE rt�� EMPLOYEE#: ®32 DATE: I <br /> ASSIGNED TO: E s C o Tr-O EMPLOYEE#: 5-t`44 DATE: 43 G <br /> yr- <br /> Date Service Completed (if already completed): SERVICE CODE: 3 (S- PIE: $r.ZG•03 <br /> Fee Amount: _ )��• �� Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />