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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RO 15 3-i265-M <br /> NER/OPERATOR - <br /> ' rbc; I _cty'� <br /> 7 CHECK If BILLING ADDRESS <br /> FACILITYNAME ��/� <br /> qxzx <br /> STEA RESS �. q/'Sp2ade f <br /> rn,,�[n '( Il i <br /> ti ['` 1 Street Number OlreMlon � �� Strae�ame�I V`� /'��C it ZI Catle <br /> I{OME Or MAILIN ADDRESS (If Different from Site Address) <br /> /-d,T 1 Vl Street Number Street Name <br /> CITY STATE 1pl� <br /> rCLC / <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> (5tb) rq9- X90 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME. PHONE# EXT. <br /> 44 2d Ad <br /> H2OME Or MA NG ADDRESS FAX# <br /> >o r <br /> CIN - S ATE ZIPg153-2 :7 <br /> BYLLING 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,Standar ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /� G /%�� DATE: �4-L(t'1 25 L am( <br /> PROPERTY/BUSINESS OWNER❑ OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. P <br /> TYPE OF SERVICE REQUESTED: el <br /> COMMENTS: C /�'1/1��Y- 111L 2 <br /> LOM19t OI VUVt Wl >hf? �JOAQIJ v�.� <br /> ou <br /> 11&4�7?1 0---P((r� AL <br /> MHT <br /> ACCEPTED BY: UA(rd EMPLOYEE#: n DATE: <br /> ASSIGNEDTO: Kwiw, EMPLOYEE#: 4 4159W <br /> DATE: - 7r✓�e19 <br /> Date Service Completed (if already completed): SERVICE CODE: O I P i E: I-Lf(1-V1Fee Amount: '�� Amount Paid I � Payment DateiL�I Z Z <br /> Payment Type Invoice# Li-9 22 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> � � LSI `li>� lj <br />