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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S-FA r, n �-K 1 S 2 fro S 'F I&A <br /> OWNER/OPERATOR CHECK If BILLING ADDRESa❑ <br /> t,.fesT c©as-/ Pro cJuctS <br /> FACILITY NAME A rCQ 6 S?O <br /> SIT EADDRESS TS EaS-t LoU, S e A v e <br /> L01rhrop 93-3 3 0 <br /> StrNt Number I Dir9ction <br /> HOAE or MAILING ADDRESS (If Different from Site Address) <br /> "l --- Strad Number <br /> CITY STATE ZIP <br /> PHONE(#'I / AVN i /! n LAND USE APPLICATION it <br /> (zU/) Q 3- 9/�/`� �V <br /> PHONE#2 EXT. BIDS Dl ,st LOCATION COpE <br /> ( ) � •�It <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> 4�q�d CHECK 11 BILLING ADORES8 <br /> BUSINESS NAME 1J\ PHONE# EXT' <br /> Ge trier - eL3clo 1r) . 1 E ,L% <br /> HOME or MAILING ADDRESS FAx# <br /> 3/Lio CojI C-cir,,P Or. U, ie /70 ( Wb) 63/ 1317 <br /> CITY 1011 v �d f do�/q STATE CG. LP 9s 67 0 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> �� . DATE: g 1�7 k C� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT fo SC-('U, C e 0-�Cp nc'J e r <br /> IfAPPL1CANT is not the BILLJNG PARTY,proof ojauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> CoMmgns: �ePl0.ce �avitt' SenSpr n �'7 ll Svr>)O. Sc-nSor IJc, S <br /> (-epictced on 9'I a7l0cdue- 10 S ; to do"ir). <br /> ACCEPTED BY: A EMPLOYEE PDATE: <br /> _1 lq7 <br /> ASSIONEO TO: EMPLOYEE* �.� , DATE: <br /> Date Service Completed (It already Completed): SERME Com: PIE !i Z <br /> Fee Amount: 3 L/S ov Amount Paid 3 Lt J 0 U Payment Date <br /> Payment TypsC,,J-,C .(-d Invoice# Cheek/ Received By: <br /> EHD 48-02-025 A 33�1 I SR FORM(Golden Rod) <br /> REVISED 11117r"3 <br />