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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#1: <br /> =� 007 <br /> ERVICE REQUEST# <br /> 5-ReI <br /> OWNER/OPERATOR <br /> '('QI'Vt (-fo(tS LE`f CHECK it BILLING ADDRESS El <br /> FACILITY NAME HTRSLE`/ PJZOPEIZTNJ <br /> SITE ADDRESS x,61100 I S• Stanley Rd. STo�-K-'�'aN 95215 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) same <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (1.011 ) *91-3.193 187-060-04 & 187-070-28 PA-1(, 002�5�M7) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R,EQUESTOR 'Foy p,NeC O CHECK If BILLING ADDRESS 13 <br /> BUSINESSNAME LIVE 0f11C GEOLtJVIRDAJr 1&-tJ7flL PH F'# Ext. <br /> go3by - 039 S' <br /> HOME Or MAILING ADDRESSA4D�, w, OrtK ST. (Z0./ ) <br /> CITY LOQ ( STATE C A ZIP 9S'3--+D <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 he 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. l L <br /> APPLICANT'S SIGNATURE: DATA:: F � I +/7� <br /> PROPERTY I BUSINESS OWNER& OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ W ,1 <br /> IfAPPLicANT is not the BtLLiNG PART r proof of authorization to sign is required Trete <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 environmentaUsite 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: REVIGw SVR-�YtkCE -t SV BSUlZf:ACC CON7�tryvAJPMDN REP02T AA'' <br /> COMMENTS: lDI2'EA 'OI21�/lV� A.� 4.y�• <br /> l.C: VFX <br /> yFA<THgOyNC O6 <br /> �I ' I oFe40 <br /> vlt NTi, <br /> ACCEPTED BY: /1 n/I Q,t II a Q yid EMPLOYEE#: DATE: /l In <br /> ASSIGNED TO: M �V 1`•�wV` l ' 11 EMPLOYEE#: DATE: 112,11(,o <br /> L /1(, <br /> Date Service Completed (H already completed): SERVICE CODE: S'(;5a3 P/E: z(?U 7J <br /> Fee Amount: Amount P a-7g` d Z) Payment Date /Z <br /> Payment Type Invoice# Check# lnoReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />