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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILrrY ID# S/E1R,,YllICEE PX;QU_EST# <br /> ' <br /> 1� 5 o twrc v\ lv 001 C I 10, <br /> r, UV O`iV� S <br /> OWNER I OPERATOR <br /> ACM CHECK it BILLING ADDRESS� <br /> FAcaRY NAME A. ktk✓0 k q <br /> S TIZ2 <br /> SITE ADDREss sv..i .r (kc'✓1't" v/ 2d -j4- 5}-oC��iTM gS2U6 <br /> Z Coda <br /> HOME or WILING ADDRESS (M DH%mnt from Site Address) S} <br /> Smog Number I tay man 6 .I Mame <br /> CITY RCAce' sra ZIP q�33 <br /> PHONE#1 Exr. APN# LANG USE APPLICATION# <br /> ( 201 I bKrt- S 21-LO <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A ` \ lcoa CHErKlf 0l"Wa ADDREsso <br /> BUSINESS NAME <br /> PHONE# Ex, <br /> Z� <br /> HOME Or MIUNO ADDRESS I ry�� 5 t FA%# <br /> ` <br /> J H ( ) <br /> CITY 1`-�V'\VeC` STATE S Zip 9 3-3 3 <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 preparcd this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StarsdTPURLATOR <br /> E and FED L ews. <br /> APPLICANT'S SIGNATURE: DATE: t 2 J 2 i(2( <br /> PROPERTY/Bug NFss OwNER 11 /MANAGER OTHER AUTHORIZED AGENT❑ <br /> 1f APPLCAMisnotthe BiLLINGPARTY 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 die <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenial/site assessment <br /> information to the SAN JOAQU[N COUNTY ENvrRONmENTAL 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: ..1-n3 p e cA�Ov-'A M <br /> COMMENTS: <br /> SEC 3 0 <br /> SaN,joA ?0?1 <br /> yFATN F MfN00NT <br /> 1 1 <br /> AcCEPTEO BY: L\ Y 2 EMPLOYEE#: DATE: 12 _ J 2 2 t <br /> I <br /> ASSIGNED TO: \ \-\\-\o,, -e EMPLOYEE#: ITE: 12 _?-.)Z)— 2 <br /> 1 <br /> Date Service Completed (N already completed): SERVICE COQ: �b 1 P/E: <br /> Fee Amount: S112- - Amount Pal /sa OZ) 210-1121 <br /> Payment Type j6CA- Invoice# Cheek# 66 Ig 2_53 Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />