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SAN JOA OUNTY ENVIRONMENTAL HOAL PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY lnm <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />& A 5 al -A -a0 ,] <br />i v <br />ExT. <br />Q4 3• Cr 3 8 <br />b "- S <br />OWNER / OPERATOR <br />-Pez:iom <br />CHECK if BILLING ADDRESS <br />X13- (Doak <br />FC—'Ty <br />S'Q'. cQ,r"� <br />FACILITY NAME V S A Rctvo (,e-' o M <br />j <br />ZIP (., V f <br />SITE ADDRESS s" <br />p t <br />C't t k ,� LN <br />V� <br />Fee Amount: <br />f <br />Amount Paid <br />Street Number <br />Direction <br />Street Name <br /># <br />Check # vl 9 S y <br />Zig) Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(dol) 3 b 0( - i k -X- <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j �� ,,((,�� �I,,� <br />�^+ `p� `V�-V"-AA <br />GEIVE <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />lse�rUkeStcL+(ori S 5 '4IAS T—.LC • <br />2 <br />s JDOAnU1S CKfv <br />H�� pEPAR��S� <br />PHONE # <br />b <br />ExT. <br />Q4 3• Cr 3 8 <br />HOME or MAILING rARDRESS <br />L060 QvLcum, Avg. <br />DATE: <br />FAX # <br />(41F) <br />X13- (Doak <br />FC—'Ty <br />S'Q'. cQ,r"� <br />STATE (fid <br />ZIP (., V f <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 />1 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: ,f V • A DATE: 43 f a6c i ,[ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 0-6"chlt.aa C-4 L fir <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required I 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. _.& R5: f <br />TYPE OF SERVICE REQUESTED: S� 1 -da <br />GEIVE <br />COMMENTS: Ck <br />" S 14I/ ,il L� .,f_ `� <br />r� (� L CTD 1 <br />2 <br />s JDOAnU1S CKfv <br />H�� pEPAR��S� <br />ACCEPTED BY: <br />:5w if <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: Z <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: .! <br />PIE 2 <br />Fee Amount: <br />f <br />Amount Paid <br />Paymdft Date Alt(/09 <br />Payment Type <br />t�Invoice <br /># <br />Check # vl 9 S y <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />