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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> �(rn fDunc� mGtn nti <br /> FP poob� <br /> CHECK If BILLING ADDRESS <br /> OWNER I OPERATOR <br /> c v b i� Reso L�v <br /> FACILITY NAMES-- ,/ YlT'U"(�v <br /> 0 rnC rinCj- <br /> Dlt>QT prn� I t / <br /> SITE ADDRESS bGt� � r� -p 0 ac�n c zl coa. <br /> 1 Street Neme <br /> '"\VV Slre•t Number Dlrecllan ) SQL I SLOW- 50 <br /> HOME or MAILING ADDRESS (If Different from Site Address street Ne • `�(JJ <br /> Steel Number MT Zip L19603 <br /> STATE <br /> Cin Cvru vl Rta( AS <br /> Exr. ApN# LAND USE APPLICATION# <br /> PHONE#t b 6517 3 C)15 <br /> ( (phn) �-1 a(Q FJ7 5L`� J LOCATION CODE <br /> Exr BOS DISTRICT <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK If BILLING ADDRESS® <br /> RREQUESTOR PHONE# ExT. <br /> 1 i� FAx# <br /> RESS{� STATE L ZIP S"'u, JS <br /> good property or business owner, operator oauthorized agent same, <br /> BILLING ACKNOWLEDGEMENT: I, the undersiMENTAL HEALTH DEPARTMENT hourly chargee s associated with this s project <br /> acknowledge that all site and/or project specific ENVIRON <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,STA C an ERAL laws. <br /> DATE: "a 'C93 <br /> a 3 '1� <br /> APPLICANT'S SIGNATURE: /� <br /> l7Pnera <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORI7,EDAGENT I eminkd,Tlfle <br /> IfAPPL/CANT is not the BIL[/NG PARTY proof of autl+orizatioir to sign is required <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 envirorunentaVsite 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: fx <br /> COMMENTS: I �b �I� ck R4St .'4— ,y�_RECF�V p <br /> alp JUN'2 8 Z 16 <br /> 5+9 ENOAQUIN C <br /> -- - <br /> ACCEPTED BY: + --- EMPLOYEE DATE: 9 �l RT WT <br /> fit-f ,� 7 <br /> ASSIGNED TO: WL EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid 1Djp — Payment Date 2gN/ <br /> Payment Type + <br /> Invoice# Check# V_ pC/SS3,6 Recelvedl3y: 14> <br /> SR FORM(Golden Rod) <br /> EHD 45-02-025 I <br /> REVISED II/17/2003 v 12 )- <br />