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SAN JOAQU, —'OUNTY ENVIRONMENTAL HEALTH L—PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-U A-15s-r4MU-11 3 S"S 2�o s y S <br /> OWNER/OPERATOR <br /> us A CHECK if BILLING ADDRESS E] <br /> FACILITY NAME I; `C n � r+ C <br /> SITE ADDRESS ����- W �� ����� � �, FSa�-�. <br /> Street Number Direction Street Name Cit �i`'Code i <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3�� S 34- y l`'�����, <br /> Street Number `t treat Nnml� <br /> CITY STATE Vi <br /> W`A ZIP / <br /> s <br /> PHONE#1 Exr. API# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR g CHECK If BILLING ADDRESS <br /> Cts •�.L.tWi 1 <br /> BUSINESS NAMEPHONE# EXT. <br /> P LP- t�aa���ec�a�,�� mac, e . 4t <br /> HOME or MAILING ADDRESS FAX# <br /> (4ov) <br /> CITY S C'LL� +Oc� STATE /4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / p <br /> APPLICANT'S SIGNATURE: 144 &LZLZI., ��. �'�-�ti�� DATE: �,�/az(aw 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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. u S �2 -c -T— <br /> TYPE <br /> TYPE OF SERVICE REQUESTED: -� c4tc,-1 C)4 --f g �.t-eL� (� 'q �-� LIL <br /> �N C <br /> COMMENTS: <br /> 8 � 6 1pp8 <br /> E <br /> F GovN <br /> sPN N�RONP RcM� <br /> ACCEPTED BY: L EMPLOYEE#: �� 3 L/ D Z <br /> zr` l•�� <br /> ASSIGNED TO: C 4 C /fin 1 T EMPLOYEE#: Z 2 DATE: -1-12 <br /> !v O <br /> Date Service Completed (if already completed: SERVICE CODE: j,9 d P I E: .2 <br /> Fee Amount: 4• C,t) Amount Paid Q a� Payment Date 2 b <br /> Payment Type Invoice# Check# '� ` Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />