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SAN JOAQUIN )UNTY ENVIRONMENTAL HEALT )EI'AWrMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SFtOC32Gq� <br /> OWNER/OPERAT R <br /> �n I UII CHECK if BILLING ADDRESS <br /> FACILITY NAME ICA r0-rA VIII PSf-a SA <br /> {� 1r.4/�;��' 1� �.1,, <br /> SITE ADDRESS I04IC '1- �V 7 1,I `1�T E FOr,+a. Z Rd 14ucI-1uh <br /> Street Number Dlreetlo. Slreel Name 1 Clt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE 01 EXT. APN If LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> ` �^ 1 CHECK If BILLING ADDR8SJft <br /> BUSINESS NAME �/ PHONE# E:r.- <br /> (�� �In � �e ( 209 <br /> HOME or MAILING ADDRESS FAX If <br /> -z,2-2-5- M r } I z St ( > <br /> CITY 5-h)d(fVvl STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned properly 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I�O h 49--1 r)-7-,e f1 DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If Al'PGCANT is not the BILLING PARTY proof of authorization to sign is required TiNe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the properly 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 HrALTH DEPARTMENT as soon as it available and at the same time it is <br /> provided to me or my representative.I y/, ,2 g <br /> TYPE OF SERVICE REQUESTED: c (T f Q�Q, O(('j 1 S 1 W yn PAYME�T(� <br /> COMMENTS: <br /> � <br /> QnI I ✓�1 � 1.��l I I� l��l t!- ��"���� � y <br /> -N�UBLI�H3A TH 5 RV GE qU <br /> �,�,,/,,� Aea��,y1T �ti�p 11�. NVI M•NlAI <br /> 40`,1 Il!V131nN / <br /> APPROVED DY: EMPLOYEE#: 2-L 8 v DATE: <br /> ASSIGNED TO: EMPLOYEE#: C C( DATE: <br /> Date Service Complete (if alreadycompleted): SERVICE CODE: SZS PIE: 2-6C -1- <br /> Fee <br /> - CZFee Amount: I J I <br /> Amount Paid Tl� y l.f S Payment Dale Imo/ �5-/j Z_ <br /> Payment Type y Invoice# Check# / I S-77 I Received By: <br /> EHD48-01-025 l./'l t -,3139 — q 7 c-gl�oQ , 800th REGJEST FORM <br /> REVISED 6-5-02 ( l 4 <br />