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SAN JOAQUIN COUNTY ENVIRONMENTAF,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LTA 00221 cis 5 Z OA-3012 <br /> OWNER IO E•p-�TQR [� <br /> CHECK If BILLING ADDRESS❑ <br /> `FACILIiY If UCjIM � <br /> SITE ADDRESS 2_22 VJ y yl e, Si Loo } 0 S;?'4'0 <br /> Street Number Hrl fion Street Name city Zip Codo <br /> *ME or-MAILING ADDRESS (If Different from Site Address) <br /> a + 4—om C-- Street Number Street Name <br /> ! �L �t S zlPgsa <br /> [PHONE#1 Ir ExT TAPN# LAND USE APPLICATION# <br /> (Za <br /> PHONE#Z EXT• 1305 DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR r <br /> REQUESTOR �[ �q 1 CHECK if BILLING ADDRESS CJ <br /> ZUSlNESSIVAME_ 1 { f 10 PHONE# , �+ ` EXT. <br /> JiOMEorMAILING ADDRESS FAxIt <br /> FGiTY'..'.�r A ' $TR�TE ZIP <br /> LUN( <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 apo that the work to- ecformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards, STA 1!an ZDERAL I S. . <br /> APPLICANT'S SIGNATURE: DA"rE:►rr� �" Q <br /> PROPERTY/BUSINESS OWNER❑ %PERAOR 1 M AGi OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Firte <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/cr environpental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available Eritt�V*�e time it is <br /> provided to me or my representative. �' ��` <br /> TYPE OF SERVICE REQUESTED: '+—Zo gu Dtr D <br /> COMMENTS: N^^, � ,nn'� �0 <br /> �I(II�V o o�T '� , ��NI N CoUN <br /> �D�p�Nrq� rl,' <br /> ACCEPTED BY: ` SAMO t' EMPLOYEE M DATE: <br /> ASSIGNED TO: V0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already com ed): SERVICE CODE: P I E: 02 <br /> Fee Amount: �� Amaunt Paid Payment Date 12-1 r s 20 <br /> Payment Type Invoice# Gheck7#' f� G�J} Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />