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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�ea.l,,4e Lo <br /> OWNER/OPERATOR A 'l CO Le -P <br /> Iv r' CHECK If BILLING ADDRESS E] <br /> FACILITY NAME S T:�>G Q-`L--� <br /> SITE ADDRESS � � St(� ��SZ C)IL <br /> f I la" e <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#'1 Exr. APN# LAND USE APPLICATION# <br /> (2ol1 '�2Q -4-22^ 1(CZ-13m-GC( <br /> P( 2 oqHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) (::;t4-9- <br /> I S -a a <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` `Iko-o „ � Y V U( CHECK If BILLING ADDRESS <br /> BUSINESS NAME K0 PHONE# EXT. <br /> HOME or MAILING ADDRESS ^ FAX# <br /> )--i l E, VYlGc—rGfn LGA l� ( 1 <br /> CITY C tch> I STATE Cq ZIP g S-2 U <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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: y�/ DATE: <br /> PROPERTY/BUSINESS OWNERV OPERATOR/MANAGE-R'E 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, 1, 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. PAY <br /> TYPE OF SERVICE REQUESTED: Y- W��1 I-�G flOrl CE��/ <br /> COMMENTS: <br /> �Joe2 � 70 <br /> E QtIIN <br /> H iVVj 0ON OUNry <br /> fPgR L <br /> A461V <br /> ACCEPTED BY: V L1 e, EMPLOYEE#: T5 3 I DATE: 2/2.-7/2-3 <br /> ASSIGNED TO: 51 `\ EMPLOYEE#: 9536 DATE: 2-/2--7/2--3 <br /> Date Service Compl ed (if already completed): SERVICE CODE: 06 P/E: L(/03 <br /> Fee Amount: 156 Amount Paid I �Po� Payment Date 2 2 2 :�5 <br /> Payment Type Invoice# 5 d � Received By: L "� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />