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RECEIVEU <br />SAN JOAQUIWOUNTY ENVIRONMENTALT PARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyEALt <br />Eet�s�-taCR Pie-oxil �•��E>��►s�FrJt� <br />AO%NWNTAL hSERVICE REQUEST # <br />fi� L-rV% to'A I:M At 0. <br />DEPARTMEN <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />� <br />1 E'SOM0 �vklito�O�(�t��tN� <br />00, <br />FAlILITYc r A�MyE ^ GGtsE <br />Date Service Completed (if already completed): <br />SITE ADDRESS :ZJ-4A f &- <br />W � <br />I <br />/ <br />i4 �iT`r✓t--Z" •w Lroctirc- <br />LA ©` <br />Payment Date <br />Street Number <br />Direction <br />Check # <br />Street Name <br />:ity <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />1, <br />%l ^� <br />6leU� V n t <br />Street Number <br />t` -i -L <br />V Street Name <br />CITY 'S � � r,_. \ <br />t VN <br />STATE -Try ZIP <br />PHONE #1 EXT. <br />L7-10 Com? 6- C ZZ�I <br />APN # <br />o S9:'- I40- c k <br />LAND USE APPLICATION # <br />PHONE #Z EXT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <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 <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/e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDFAXIL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER <br />IfAPPL/CANT is not the <br />OPERATOR// MANAGER ❑ <br />DATE: 111_2 L 420 L4/ <br />Ir <br />OTHER AUTHORIZED AGENT kift-k- r'cilIa— cytj�. TO M <br />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 �Q0p'1•LW�rp ��k Nba <br />COMMENTS: .4;J:0PC OF %OCJ iV�C- t S -M V-S4LJ*CAF- Ex%N sl �tF/L <br />Jb% Tee-JSZF t S' <br />wl N VAAJ �aI l-twc%' W -IoO- S C3 t fl � �-� F�TEt. "D,SFreo-WM-C . It3 S-VAAA, <br />W'0'W •i6CL440 %-6ttr NSA) %>%S?aP&6gS <br />CptJ V ecr� � S� St 2- �a �l� i! �T` -t-o $PsLAt-)C� --' S—,e't-A . <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />-Tzw\rq' <br />SG.7�E <br />b� <br />