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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b � l 100 y q I Iq <br /> OWNER/OPERATOR <br /> `SU ,(C 1 ( S Y �S CHECK If BILLING ADDRESS <br /> FACILITY NAME n / _2�^ <br /> SITE ADDRESS (�I /�/, r I S (/�, rt� (I/J a{— <br /> Stfeet Number Directlon `' ( Street Name CI V 21 Code <br /> HQM i D ING ADSD SS (If Different from @ AddC <br /> UV Street Number Streot Name <br /> CITY Q C STATE ff� zip ��G <br /> PHONE#1 E., APN# LAND USE APPLICATION# <br /> (650) 12-0 _ o <br /> PHONE#2 Exr• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Ear. <br /> Sorge S <br /> IiQME Or MAILING ADDRESS FAX# <br /> rL 4 S S y t2i y CYee4< C_- l ) <br /> CRY STATE 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 /> 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: BUY O(f C 0 4 e V aS DATE: 00- 12-3 - iL <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLiCANT 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. po �/ /� <br /> TYPE OF SERVICE REQUESTED: M D L V C w Si.A I �iOn <br /> COMMENTS: <br /> 41JGO <br /> ?3 11 <br /> M NOFpNFN Ory <br /> ACCEPTED BY: S, EMPLOYEE#: DATE: i/ 3 <br /> ASSIGNED TO: ( EMPLOYEEM DATE: !� <br /> Date Service Completed (if already completed): SERVICE CODE: q PIE: I <br /> Fee Amount: .60 Amount Paid (5 a Payment Date 6'1-2-51:24 <br /> Payment Type 0AILdInvoice# ?J C>23 Received By: OA <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />