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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PA 0531505 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 6� �- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME I�f a ti l S ULaV-e. ( 1 # Ll L I< I�0 2- <br /> SITE <br /> SI.1'b(D,DRESS ll u vt$ d Ca I7 for nl A <br /> 1�" Street Number Directlo Street Neme Clt ZI Cotle <br /> HOME Or MAILING ADDRESS c(it Different from Site Address) <br /> aD - V w���� Street Number Street Name <br /> CITY STATE ZIP <br /> C* q C0q0-(1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( POA) &" — (r'I D C <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORIT <br /> P��r Poi O s Lr L t� � CHECK IfBILLINGADDRESS <br /> BUSINES NAME C "-'l' i -tiC. PHONE# EXT' <br /> S� S l acyl i --"Ci f <br /> HOME or MAILING ADDRESS FAx# <br /> 30 s rt- w Sit- ( ) <br /> CITY S{.�-. 1.)�.... STAT ZIP <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 be billed to me or my business as identified on this form. <br /> also certify that I have prepared this applicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand nd DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ( D (p <br /> PROPERTY/BUSINESS OWNER L7 OPERATOR/MANA R OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Titre <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 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. Amoco <br /> TYPE OF SERVICE REQUESTED: Mob ( L ,� NT <br /> COMMENTS: <br /> 0,jn-erJAj p 6 2020 <br /> S4N JOq <br /> QU <br /> N DEPAR M NT <br /> ACCEPTED BY: ( � fY11 ,c EMPLOYEE#: x( DATE: [0110 h-0 <br /> ASSIGNED TO: Vl.t Vl `7 EMPLOYEE#: U �q DATE: b <br /> Date Service Completed (if already completed): SERVICE CODE:Y UPIP 1 E: <br /> Fee Amount: VJZ'U(] I Amount Paid �a! Payment Date (a2� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 C O :l 5 l2 g SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />