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SAN JOAQUI-.OUNTY ENVIRONMENTAL HEAL I DEPARTMENT <br /> SERVICE REQUEST <br /> Typ4of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L11fo,41DRCKA2A Sl200-150707 <br /> OWNER/ OPERATOR <br /> oN 6A-RB A 3• CoNs7-RGCcr/ 0A/ /AIG - CHECK If BILLING ADDRESS <br /> R <br /> FACILITY NAME <br /> SITE AD RESS 5,1nA 20 Q-D /1A Maack el/S-336 <br /> / 0 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different <br /> from Site Address) <br /> /O 4// 5 MA I- Ra Street Number Street Name <br /> CITY /1AaT-GCA STATE l ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATIO <br /> ( ) 96q ! 2119 i77 -090 . a . /A 3- S� <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> O/V �//G r�w '4 CHECK If BILLING ADDRESS <br /> BUSINESS NAME 'V /T 'V PHONE# EXT' <br /> C�E NE o.t/fu�Tii✓ ((P-/4 0 3 <br /> HOME or MAILING ADDRESS FAx# <br /> o . OCK 3 7-7:4 0-z�18 <br /> CITY I LO STATE A ZIP 30 / <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 applicat' and that th york to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Corlcs,Standards, STAT d FEDE <br /> APPLICANT'S SIGNATURE: DATE: /O 7—0 3 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MA AGER ❑ OTH t AUTHORIZ.EDACFNT❑ <br /> /fAPPLICANT iS not the BILLING PARTY proof of mrthoriz tion to sign is required Tide <br /> AUTHORI7ATION 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 /> infonnatiott to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5L{1;?`A`E <br /> COMMENTS: /Zw,AA/a=/ - Z f PAYMENT <br /> rte" wV•'� /1`, �+„_' RECEIVED <br /> (. � o K OCT 17 2003 <br /> SAN JOAQUIN COUNrA pJal ir WVAI TH TY <br /> (' <br /> APPROVED BY: EMPLOYEE#: 4011Mry 'VATE� (/r e;lrj <br /> ASSIGNED TO: EMPLOYEE#: �� DATE: 0r-./ r <br /> Date Service Completed (if already completed): SERVICE CODE: 5'P4 a— P 1 E: 26„fJJ,3 <br /> Fee Amount: G Amount Paid — Payment Date $ ('7 v 3 <br /> Payment Type Invoice# Check# IllReceived By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />