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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �SERVICE REQUEST# <br /> o ercx UI AI)i <br /> OWNER/OPERATOR <br /> sexMay-Co uZ 1 ret �/I CHECK if BILLING ADDRESS <br /> FACILITY NAME O C Q rn u S C-OC' t9 n CA �2o 3 <br /> SITE ADDRESS /�✓7 J S /////���I /II C/�� ' _✓PJ��'I`���1 <br /> reel N0ber Dlree n ✓ t/l Slreel t e �Zi C tl <br /> HOME or MAILING ADDRESS (If Different from Site Address _ <br /> G C Street NubermG I`�l Slreet Name o <br /> CITY STATE ZIP <br /> C <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> (20P ,2, tlly6 <br /> PHON # i�C/J ExTBOS DISTRICT <br /> 9OO LOCATION CODE CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /� O� <br /> - ( , r � ��L CHECK If BILLING ADORESSL <br /> BUSINESS NAME v I t/6 0� PHONE# ExT <br />`- C( © v- s Cos 5 t r1 to ct, < 3s 2 0 <br /> HOME Or MAILING ADDRESS FAX# <br /> ! C ,-eer, d e ( ) <br /> CITY L ©c, I _ ri STATE zip � 5-.2 QQ <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 /> 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. �J <br /> APPLICANT'S SIGNATURE: RAS t c,rU2�� U2_ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> V, Qo•/�qeCLuislDp�z Itlet13 fp <br /> � O�8 <br /> r7a- e0 Y- 1 iX��2rd0•�e� <br /> y � ONM Cp�N <br /> ACCEPTED BY: Lt(-O- EMPLOYEE M DATE: <br /> ASSIGNEDTO: �1/q I % EMPLOYEE#: ��� I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E; 1U0 _9 <br /> Fee Amount: -U Amount Paid �5 Z Payment Date /,-/g/9-0 <br /> Payment Type Invoice# Check# Received By: L-6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />