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SAN JOAQUIi COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />in irr-gL <br />J., FACILITY ID # <br />'.---I g 17 <br />SERVICE REQUEST # <br />5 epo&og5 <br />OWNER/OPERATOR <br />A P T 13 6' 1 z.— z- <br />CHECK if BILLING ADDRESS El-- <br />FACILITY NAME <br /> ilS ..., SITE ADDRESS, 1 i , 7-4/6— <br />E33 S- VI Street Number Direction PP,T# /7/ JY ' 4.1Yq— Street Name RiteAll-er) City <br />-0 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />i i, Street Number Street Name <br />CITY STATE ZIP <br />PFIT #1 EXT. <br />( IA 73 ---. 2_67 L/ <br />APN # LAND USE APPLICATION # <br />PHONE #2 6.17 LI <br />(9A, <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( / <br />Ex 1 <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />Crry STATE ZIP <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, Standards, STATE and FEDERAL law <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWISEdzi <br /> <br />DATE: <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />"[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. <br />TYPE OF SERVICE REQUESTED: -0-0 .(2 ik --tyel- ..t-t-) c'em—p--etd — (Q% • ow r YMEN7 COmMENTS: RECEIVE <br />AUG 19 2C <br />ENVIRONMEN1/- I <br />SAN JOAOUIN CO, <br />HEALTH DEPAFITML pOpr <br />ACCEPTED BY: 4 <br />' <br />EMPLOYEE #: ( d f 3 <br /> <br />/ / / j , DATE: 3..c • / (--, <br />ASSIGNED TO: fl ' <br />24- et: 1-4.-15-e-( EMPLOYEE #: 6_ 2_ / 3 DATE: <br />Date Service Cpmpleted (if already completed): SERVICE CODE: 'S-- ) -7_ PIE: 3 ; 6) <br />Fee Amount: (., -12). CP( t i -/), Amount Paid iti g-c.t 4 , 0 CD Payment Date -i (1 I c.:" <br />Payment Type kr.7 Invoice # Check # /341 Received By: lize <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />uSWC 55