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SAN JOAQU N COUNTY ENVIRONMENTAL HEALTibDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A-5 <br /> -A- <br /> 9-1 at 0 <br /> OWNER/OPERATOR lsCHECK If BILLING ADDBE§11:3 <br /> FACILITY NAME Skl--U <br /> SITE ADDRESS :_Z 1 W Gm-at Lzt"-� -ILd <br /> Street Number I I)IM91120 %Mst NAMIit <br /> 912 Q290 <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> .IoqqS- <br /> street U0 Street Name <br /> CITY y STATE zip qCm- <br /> CAX�S t"A <br /> PHONE#1 E., APN III LAND USE APPLICATION# <br /> ;HONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> rp(, 11 <br /> CONTRACTOR SERVICE REQUESTO <br /> REQUESTIOR a <br /> R <br /> CHECK if BILLING ADDRESS IP <br /> BUSINESS NAMESPHONE# EXT.twulx- 0, An <br /> HOME or MAILING ADDRESSFAX# <br /> (0%0 UQLvLiA Atw, -±d ) <br /> CITY 6-tlk C Ac- STATE (2A- ZIP <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: Lzb V. 1�t - '�� DATE: I/ t acinq <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AIANAGER [3 OTHER AUTHORIZED AGENT U <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> ALIBOBIZ,ATION IQ U ASE 1NFQMATJQJS: 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 /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I Amount Paid —7—payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />