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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT'L U 7 2011 <br /> SERVICE REQUEST ENVIRONMENTAL <br /> Type of Business or Property FACILITY ID# SE MIMMIR ir(#ES <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME U('h /l-� o Ve �. !(7( � <br /> SITE ADDRESS <br /> Street Nu oer Diractio 04 Street Name J I• "`I` `�I <br /> oe <br /> HOME or(HAILING ADDRESS (if Different from Site Address) <br /> Street'..,: Street Name <br /> DIN STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Exy• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i CHECK If BILLING ADOR@SS <br /> BUSINESS NAME L-t �� E0. <br /> HOME or MAILING ADDRESS ' Q <br /> �J r k� <br /> ( I <br /> CITY STATE zip <br /> qyml <br /> BILLING ACICNOWLEDGEMF✓NT; 1, 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!OAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an E(� taws. <br /> APPLICANT'S SIGNATURE: �-74 <br /> \ ` DATE' <br /> ?ROVE:k'I'Yit�L51-NES.SOWNPR❑ OPRR,�TORI'MANAGFR El {tRAu-m0RI7Fr)AGENTG� <br /> � <br /> 1 APPLICANT iS not! BILL/N f PARTr proof of authorization to sign is required rime <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> r. ^ " above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> r.,. information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HFAim-i DI PARTMI7NT aS Soon as it is available and at the same time it is <br /> provided Co me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> RECEN - CCtdMEh�;; � / <br /> L _ � A r� rah UPI h CoMf �a <br /> ,U )1A, <br /> t� <br /> ACCEPTED BY: LEJ w C EMPLOYEE#: Q ps nATE: 20 f <br /> ASSIGNED To: �� EMPLOYEE#: Z ) DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G I P I E; <br /> Fee Amount: Amount Paid tf. Payment Date / <br /> Payment Type Invoice# A Check# Received Bly: <br /> EHD 48.02-026 4I t <br /> REVISED 11117/2003 5R FORM(Golden Rod) <br /> �,�:a6ted 82Tat?9t?602T:01 0t7TTL9S9T6 3t7TTZ9S9T6:WOJJ 22:2T TT02-ze-nnf <br />