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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />SERVICE REQUEST # <br />LS 12-006, /0 <br />CNECK If BILLING ADDRESS <br />OWNER / OPERATOR <br />Type of Business or Property <br />FAciurv NAME rr I r i 611 <br />SITE ADDRESS <br />ieN iv\ 0 hh,, Ftt 14— <br />Sweat Number Olfaction es Strew N me S41C4City HONE or MAILING ADDRESS (It Different from Site Address) <br />_lb 10-111 <br />Ell, coda <br /> <br />Sicilia( Number <br /> <br />Street Name Ciry <br /> <br />STATE ZIP <br />PHONE SI EaY. APN <br />913 Y()() <br />LAND USE APPLICATION • <br />PHONE 02 <br />REQUESTOR Lit <br />BOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />LOCA • N CODE <br />CZ <br />CHECK a) NG AODRCs <br />EXT. <br />BUSINESS NAME <br />LS J.1 <br />HOME or MAILING ADDRESS <br />EXT. <br />S Y.' 42'17 <br />1144A-bcyl_ STATE at Zie <br />BILLING ACKNOVVLEDGEMENT: I, the undersigned property or business owner, operator or authorize acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associate Or activity will be billed to me or my business as identified on this form. <br />PLICANT'S SIGNATURE! ..., <br />ft;___2koek:itri Hi:Nu:less 1'i fl PRRA1 OR! MANACI,R OTHER AUTHORIZED AGENT <br />BILLING_P ARTY proof of authorization to sign ts required ... tilliORIZATIOAlp_RELEASE INFORMATION: When applicable, I, th e owner or operator of the property located at the <br />rifle <br />abovt site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMRNIA HEALTH DF.PARTMENT as soon as it is available and at the same time it is pieNified to me or my representative. <br />TYPE OF SERVICE REOuESTED: <br />Qblv rv dinunce Codes, Standards STA rE and <br />so certify that I have prepared this application and that the work to be performed will be done in accordance with all ILN JA AN JOAQUIN COUNTY <br />ENVIROMENTAL —V-1976111VDEPARRI4 ENT <br />II APPLICANT it not <br />L laws. 7 „ <br />DAtE: <br />vi_ P1 Z <br />MA <br />calmEN;3: vkski svis tS„>,‘ -veA' <br />jp,„:„ co irAct ok,r6 fr-t5 (:"Athlkft. ,ve 41 Weil dif( <br />AccEPTEo e- <br />Fee Amount: <br />Payment Type <br />ASSIGNED TO: tit,, <br />Date Service Completed (If already completed)! <br />Amount Paid <br />Invoice # <br />EMPLOYEE #: <br />EMPLOYEE it! C. -c.7_ •,. DATE: t . <br />SERVICE CODE! 5-2 ? 1 PIE <br />isktLi t4 ---- Payment Date 3127 ( \ <br />Received By: <br />Cheek # <br />ENO 48.02-025 <br />REVISED 1 1 /17 /2 003 <br />6/2:aeed 2.1132..82-t7602T :0 1 lEtt7TIL9S9T6 <br />SR FORM (Golden Rod) <br />13bITL9S9T6two-ld It7tOT TT02-t70-NUf