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SAN JOAQUitOUNTY ENVIRONMENTAL HEALWEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />e....-0-rvI ryA dtru. itAX / til‘u L r `1,.--e <br />FACILITY ID # <br />.. --- <br />C Z - <br />SERVICE REQUEST # <br /> (A 7 <br />OWNER! OPERATOR <br />6 /) 9 r- Kat1 /4 11.0(k. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME M <br />/ 1 01 Pil onc--- 'YCUNI <br />SITE ADDRESS ,3 0 \ <br />Street Number Number Direction <br />j) , et- ii, c---t- I - <br />Street Name <br />5tvc.k&ovN <br />City Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 Evr. <br />( ) <br />BOS DISTRICT i LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />C <br />REQUESTOR pI <br />ik <br />. til aLc <br />. c t Ifr(CL-Lc'~9' <br />CHECK if BILLING ADDRESSIZI <br />BUSINESS NAME I ilc . <br />PHONE # ( L/(- ) aii 3 - zs- og <br />EXT. <br />JADMF-Gor MAILING ADDRESS <br />3c .3 <br />" 4. <br />Z 5t . Sie -; oo _S0 „--tk <br />FAX # <br />(qt r) IM6—ocIcec7 <br />Crrv t ,, <br />i (..A.1,,. Frot-00....i_er 0 STATE <br />(4- <br />ZIP ci 40 07 <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. <br />APPLICANT'S SIGNATURE:2 /474 1/4 DATE: <br />PROPERTY / BUSINESS OWNER0 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: /vizi, ,___- EMPLOYEE #: () )i/ DATE: 7 <br />ASSIGNED TO: t'4" i, EMPLOYEE #: <br />n11/ <br />DATE: 1 1 <br />Date Service Completed (if already completed): SERVICE CODE: % PIE. -z 0 3 <br />Fee Amount: 1 , --, Amount Paid , 1 1 <br />i ' 7 <br />Payment Date <br />Payment Type I Invoice # Check #i , <br />r -4 '..1 r---- <br />Received By: <br />OTHER AUTHORIZED AGENT 11 /0„, <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 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 />OPERATOR! MANAGER 0 <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003