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__ ;, . ,� <br /> SAN JOAQIJ0 IOUNTY ENVIROk:MENTAL HEALTP"-IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID#. " SERVICE REQUEST# <br /> COrM/1'tERC/LtL \,'_ �i �� Jr 0�,5 <br /> OWNER/OPERATOR .CHECK It BILLING ADDRESS <br /> I <br /> FACILITY NAME ksC TQ VEL CEn'FM2. . <br /> I <br /> i SITE ADDRESS �/a93 ��S' IWAN,T/-/,5y, �,. 4ATHROP 1? <br /> O5-3 <br /> Street Number Direction f i Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Differenifrorn Site'Address) ,J/a9J7 `SOG7T/� rYIANTi-/E�/ <br /> 6 '� �' Street Number \� Street Name <br /> CITY TE ZIP <br /> /,4 7'14r-' STA <br /> 0P � � •_� ,EI CA 95330 <br /> PHONE#1 / EZT. APN# `, 11` LAND USE APPLICATION# <br /> (ao9 ) 2 34 -`t 850 � `. \\/l9/-,`� ,o - <4 i (�A - o80oi0a c.P <br /> PHONE#2 EXT. -}� `�% BO$DISTRICT t.00ATIIOON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORT� J <br /> LQ 'i CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# El, <br /> C H�SnI NScc�T ( -/ o <br /> HOME Or MAILING ADDRESS FAX# <br /> ok 37 9 ( ) <br /> CITY LO STATE /t!t Zip S <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 ap ication and in t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,PYTE and F laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> � <br /> PROPERTY 113U SINESS OWN ER El OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT,L]I <br /> V IfAPPLtCarvT is not the BILLING PAR TP proof ofaut orization 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: <br /> IVI��71//T/1ftTE LlJ,q Di/�/ SD/S SU tAdB/G <br /> !� (/¢^^•�"/Iyr ..r(''� � 1 RECE/V <br /> COMMENTS: NT <br /> JUS 12008 <br /> s <br /> N ROUIN OOU <br /> "Eg0T4 N11 MftVT NIy <br /> ACCEPTED BY: ©Li.�/ (� it EMPLOYEE#: 6 3 Z' DATE: / "6' <br /> ASSIGNED <br /> ASSIGNED TO: aEMPLOYEE#: 737 DATE: —7 <br /> Date Service Completed (if already completed): SERVICE CODE: 5' PIE: a.(a D2 <br /> Fee Amount: D, O L� Amount Paid 9 O Payment Date -1 N o <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 f SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> t <br />