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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR b 5 l ? I q D <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SKONIV t 3 <br /> I+OWNER/OPERATOR <br /> �r CHECK If BILLING ADDRESS I] <br /> ` <br /> r -OL I 1�t7 WlE /n/ 2 <br /> I <br /> FACILITY NAME*, 7DI rri� T jf <br /> (SITE ADDRESS-7 3 O 5 - <br /> �- SoU�ln Cali fnfa- st,CKCou1 q:ZI 2I'D <br /> Streel Number Direction ireet Na a Cit Code <br /> ,HOME or MA'IL'ING ADDRESS-(If Different from Site Address) <br /> ., l West -7-r <br /> W~ Street Number et Name <br /> CITY STATE ZIP <br /> 'ISf Ca 520 E <br /> (,PHONE#1..J EXr. APN# LAND USE APPLICATION If <br /> (20T S 9 9s — 57 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR"7 <br /> CHECK If BILLING ADDRESS <br /> O.Yla aAa <br /> {"BUSINESS NA E'�ti _ (PHONE# EXT. <br /> 11 •Q 0. m0. vt NATks' —2 S-7 <br /> HOME Or MAILING AD ESS FAx# <br /> Tin -C - I ( ) <br /> 'CITY Lto ESTATE ZIP S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 7OAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: lg;;5- p 20 YYr—YZpTE�^7 <br /> PROPERTY/BUSINESS OWNER El OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT 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 7OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ` ' I^ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 44R? O <br /> 4 20 <br /> '-AQUI ?1 <br /> ACCEPTED BY: I,t EMPLOYEE#: 'h DATE: 2 {y y <br /> ASSIGNED TO: MAO <br /> EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: ��I P/E: <br /> Fee Amount: IC�2 00 Amount P 1s-:J e Payment Date Z J <br /> Payment Type Invoice# Check# l22-6 /3 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />