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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#' I <br /> OWNER/OPERATOR <br /> 13,A.4.0a2A CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 101o'19 ME t}tf m-1 RDA.D C-L.F�,AASNTS ?5ZZ7 <br /> S[r¢et Number Direction Street Name Ci 21 Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> (?oil 7`1 — 335 o2,3-®7,0 -05- 'Z1 Pry <br /> PHONE#PT' BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M(K,6 <br /> y M6 T � CHECK If BILLING ADDRESS <br /> BUSINESS NAME l bV PHONE# En' <br /> DtUaN Iuuapll� 2 7;4_603 <br /> HOME Or MAILING ADDRESS FAX# <br /> (3e < 2180 ( 74 334-QTL? <br /> P.O. <br /> CITY L10r'. STATE c. ZIP 2 241 <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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE andscKdLl S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY Proof of authorization to sign 1s 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- Sv (L ME <br /> COMMENTS: VFX <br /> IrAIIC ,}t,1�. tSk UG 19 <br /> SA A2016 <br /> N <br /> 1,1,0 w fNOAQUiIV C <br /> At 111 llo A TM`Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 522j P 1 E: <br /> Fee Amount: 2 �a Amount Pa ;�7ff )LI)� Payment Date i7 <br /> Payment Type 4 Invoice# Check# 33 Receiv of By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />