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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or FACILE I SERVICE REQUEST# <br /> i4 Z SI�Ut)RVSq <br /> OWNER/OPERATOR <br /> pa-m I ..eKI-r` CHECK If BILLING ADDRESS <br /> An�C�RES <br /> Ft/ <br /> FACILITY NAME 2UZ�PF y(�C;tA ,rte <br /> SITE ADDRESS 1VISL62A W KST-ft,15 AN L-N , STF [Z,6 <br /> Street Number I 01mction I Stmt Nam. city Zip Codo <br /> HOME or MAILINGADDRESS (if Different from Site Address) //'�� ` I- <br /> S r�J Street Number " L J Stmot Nam. <br /> CITY � M miewr] ,STATE <br /> y5$55- <br /> PHONE91 En. APN# LAND USE APPLICATION# <br /> ( 530 ) 210 080 <br /> PHONE#2 \ Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEQ r PHONE G <br /> HOME or MAILING ADDRESS `J -� FAX# V <br /> CJ1 I ) <br /> CITY j Jam, STATE CA ZIP Q G <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator q or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL IIEALTU DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 Codec,Standards,STAT and PERE laws. / <br /> APPLICANT'S SIGNATURE: G=�( DATE: 03((72 707-3 <br /> W <br /> PROPERTY I BUSINESS OWNER rOPERATOR I MANAGER ❑ OTHER AUTNOmZED AGENT❑ <br /> IJAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Tilte <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 IIEALTII 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: <br /> O <br /> SA At FFB 03 7073 <br /> NEgCrkfINg AtZN <br /> ACCEPTED BY: EMPLOYEE#: <br /> DATE: Z 3 'L Nl <br /> ASSIGNEDTO: EMPLOYEE#: Usti <br /> s u DATE: -2� 3 Z <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: _1 <br /> Fee Amount: VD n Amount Pai0l, /S�rD� Payment Date 3 <br /> Payment Type' Invoice# Cheek# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />