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SAINT JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prope(ty FACILITY ID# SERVICE REQUEST# <br /> Corlve lirme cr- I �+ ;=f� 00 133 �. 5� 00� Gc�l <br /> OWNER OPERATOR ��r,haml fc�Z � <br /> S <br /> n �} 322 L. 1\ CHECK If BILLING ADDRES <br /> FACILITY NAME Ln�2 <br /> rT �L p <br /> SITEADDRESS i .322 c�-C�"1 f liQ�7 L��y <br /> i Street Number FDiredi.. l `Sttmet Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Differ e t from Site Address) <br /> J to i A4 rAI e— 4201. Street Number Slreel Name <br /> CITYi h 7E Z44052) <br /> P ONE�#1 ET. APN# LAND USE APPLICATION# <br /> PtHOONE#2 n��ttyff���'� I=• BOS DISTRICT LOCATION COME <br /> 45_&)2_6Z 26 CS3 <br /> pCONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i r O I <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAt17E 45 '61 � � • ( E# n ! 6 <br /> HOME or N DDRESS FAX# <br /> O JALcI ( ) <br /> CITY s L R • c 5T LP 731400 <br /> BILLLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge ithat all site land/or project specific ENVIRONTMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed tb 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 law <br /> 1 <br /> APPLICANT'S SIGNATURE- /ISI�° DATE: <br /> PROPERTY/BL'SLNESS OWN OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ'APP!✓CdTJT is not the BILLING PARTY,proof ojauthori:ation to sign is required Tire <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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same,S( .t is <br /> provided to me or my representative. RIPCIE 1) <br /> PAYM 1 <br /> TYPE OF SERVICE REQUESTEDi: �"v""r V <br /> COMMENTS: A In__1 �.i�..n irj„•„� �y� ��� p,u7,s2Z <br /> liV GIN 4/[L/r`W Ur✓If-+ .Y� �"'/''� ,•�IFV;NUNuervrtu.� <br /> /� �� / � X11+I IN 1]ltNNfMF.Nr <br /> ACCEPTED BY: \ a EMPLOYEE#: DATE: 2—Z3,2 <br /> ASSIGNED TO: Q� EMPLOYEE#: DATE: <br /> Date SeN)ee,Completed (if already completed): SERVICE CODE: Obi PIE: 1 <br /> Fee Amount: j-S -a- Amount Paid S� _ Payment Date 2- 'L - Z 2- <br /> Payment <br /> Payment Type Invoice# Check# 33xCiLHI <br /> Received By: <br /> EHD 48-02-024 I '3y SR FORM(Golden Rod) <br /> REVISED 1li172003 1 <br />