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SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SC�s i t ( r . i I I SRoov(oeq 9 <br /> OWNER OPERATOR i <br /> _ L� ��^S L- CHECK It BILLING ADDRESS <br /> L ` <br /> FACILITY NAME _ ' <br /> SITE ADDRESS �p'{Q.}i-15 `( � Y�(�Ctt(TCCGC. C�37��" <br /> Street Number Direction –ter Street thrre cityCede <br /> HOME or MAILING ADDRESS (It Different from Site Address) - <br /> i�) )Z' _ _ Strout Numberstreet Nw. <br /> CnY STATE i I zip r-• i ' _ <br /> PHONE#f EX7• APN# LAND USE(APPLICATION# <br /> (,A105014,93s <br /> PHONE#2 E'T BOS DISTRICT LOCATION COOE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if EN <br /> BUSINESS NAME PHONE# etvscil <br /> HOME or MAILING ADDRESS FAX# OV2 9 2022 <br /> CITY STATE LP ENVIR�NIIV co <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized age 46*160"' <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 applicati t and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: '241..a9 {L <br /> PROPERTY/BOSINEss OwNERO OPERATOR/MANAGER C ` OTHER AUTHORIZED AGENT[3 1751 sUi ei. erf <br /> IfAPPL1CANT is not the Bl7uwGPA,R 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: G. ) <br /> ,e 1aC� Y allt4tI x�d ire • /tri (��'c lay k 1S f(e <br /> W � do n�� ��pl� d� YY>U K� cz ! <br /> �c rz <br /> ACCEPTED BY: �(� C EMPLOYEE M © b 1 <br /> ASSIGNED TO: EMPLOYEE#: TV3 $ DATE: / 2� <br /> Date Service Complet d (if already eompl d): SERVICE CODE: Q / P I E: 'r <br /> Fee Amount: ��j 6,OL) AmOunt Pai Payment Date 1112-112--1- <br /> Payment <br /> zy 2--1-Payment Type �_ Invoice# Check# 153 `6D 3/y3 Received By: <br /> EHD 48-02-025 r r SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />