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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT S(c ZD <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5i%305 - 7 ,9--(1-3 <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br />U) e ..c.-_-,k --C)(7). Y\ \ Q..- 1\-,.0._<-(s.\-e_,Ats - Si?(-_ N"\ ,-„..• ."-c->e•\. 1_ <br />SITE ADDRESS <br />0-141 .5 <br />Street Number <br />i\J <br />Direction <br />Licf--`,.k 1- e•x.n ..._. <br />Street Name <br />-\m,c..,"\i-N \r, ,-\ <br />City <br />Is 2c <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(2-0'A) L\ --P i‘ 5\ LI L.; <br />APN # <br />0 Li <br />LAND USE APPLICATION # <br />PHONE #2 E. <br />( ) <br />BOS DISTRICT. LOCAT?N CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />(LCI' ) <br />Exr. <br />HOME or MAILING ADDRESS <br />10 c., 0 NI" .t--,ny-oT c„.., -e.._.. SINN <br />FAX # <br />(10 3) <br />' <br />545.24,4g <br />CITY r., <br />VS\ 7ocsyl <br />STATE <br />C A <br />ZIP <br />9 s---34:,b <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 or <br />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 laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / ANAGER OTHER AUTHORIZED AGENT Con\ EvA016C-- <br /> <br />If 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: P__-C i•-( E4-L-7W ,2--&-.4--e 6-0E4— P t---'4--"-) c 14 € cCPAYMENT <br />COMMENTS: RECEIVED <br />MAY - 7 2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 69,c_i_ LAE i i, „4_ EMPLOYEE #: 0 24 DATELs- b (69 <br />ASSIGNED TO: a kg_4(e,g_sc 0 EMPLOYEE #: 0 ct (.77 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ..s- az._ P/E: 3(06 2___ <br />Fee Amount: 4 2t 0 • 0-0 Amount Paid ak, 6 — payment Date 5 ( 71 O <br />Payment Type Invoice # Check # 1 0 t IS-- Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003