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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LTA COL-u--- AE :Arw So0 S U� �D <br /> OWNER/OPERA.TOR <br /> /i t tom tp: CHECK If BILLING AD0RE5S� <br /> FACILI2 NAYi„El� �1 <br /> SITE A�DDRIrj <br /> �iESSSS /[ S' � ?1/ 'f <br /> /' o <br /> 2 <br /> Street Number Olrection /t��C. 1 (Street Nam Y cit Z LID Code T <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Err. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REtall��sro, Rl <br /> r ( CHECK V BILLING ADDRESS E] <br /> Bus sS NA�MePygNE ^ p/ t- W7 tgl( 7 <br /> HOME or MAILI DDRESS FAX# y O( J <br /> / �/ ( ) <br /> CITY „' IL '» STATE.. ZIP �S <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,C Standards STATE and FEDERA—laws.APPLICANT'S SIGNATURE: 1 rA�y{ DATE: 7�/ / t p� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER) OTHER AUTHORIZED AGENT❑ M191&rr fCN•iQ1JC `q w;4 <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: L� <br /> Marx • 5 hovve.rs Lo de /-/-a colb,9-e , -e dtu ” -..t ) 7 ZOZi <br /> ,J 'AN SpA <br /> QU <br /> S1VV1'�0'V1AVCOiJ n' <br /> iI D Q L �� 1 R GO y=A r0IV <br /> . N <br /> PgRr <br /> ACCEPTEDBY: <br /> EMPLOYEE DATE: (-� ^ / <br /> ASSIGNED TO: ^ v h✓t c �-Y\ EMPLOYEE#: DATE: _0 Z <br /> .1 <br /> L <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: /�OG <br /> Fee Amount: i Amount Paid QffJV b Payment Date 24 <br /> Payment Type Invoice# ehuM# 22 23��QG�o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />