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SAN JOAQUIN COTTNTy ENVIRONMEri TAL MALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIt1TY ID# � S SERVICE REQUEST# <br /> OWNER/OFERATOk <br /> CHECK if BILLING ADDRESS <br /> Cr'I C 6 AS CLC-C-1r CA L. <br /> FACILffY NAME <br /> 5 c s l CE, C c7A I 72 <br /> SITE ADDRESS 4c)46 wi e S K-f_- <br /> SbM NumEer DI bn Sb Name n Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number I trcet N me <br /> CrrY STATE LP <br /> PHDNE#f EXT. APN# LAND Uae APPLICATION# <br /> Gy Z - 152 �- <br /> PNONECExr• BOS DISTRICT LOG4710H CODR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> (D � / CHECK If BILLING AODRE34 <br /> BUSINEss NAME _ n -PNf , Nc PtT#- E U <br /> HOME Of MAILING ADDRESS -7 Ic� (A7I7 <br /> 1� <br /> CITY u e / I r STAYS /O LP c7 <br /> /o <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 ^FEDe E laws, / e� <br /> APPLICANrs SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR IXANAGER LJ OTHER AUTHORrzEDAcrNTI <br /> If APPLICANT Lr not the BILLING PARTY proof of authorization to sigw is required Tide <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 enviromnental/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; L (J C (`• 62Al <br /> COMMENTS: PAY M 1 <br /> RECEIVED <br /> NOV 2 4 2004 <br /> SAN JOAOUIfNCOUNTY <br /> PKIN/Igop <br /> ACCEPTED BY: �',LT �;�, K'- EMPLOYEE#: HEALTH D MEN/ 24 C% <br /> ASSIGNED YO: �� CKS EMPLOYEE#: �)-2-3 DATE: (i -_q �1 <br /> Date Servlrie Completed (If already completed): SFP—XE CODE: I PIE: -�_3 C; <br /> Fee Amount: ",l79' c 0, Amount Paid 9 c7 Payment Date I ( 12410 <br /> Lf <br /> Payment Type Invoice# Check# l 87 Received By. 2A. <br /> EHD 4602-025 SR FORM(Golden Rad) <br /> REVISED 11/17)2003 <br />