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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � S <br /> OWNER/OPERATOR �>z15 M�L6. CHECK H BILLING ADDRESS <br /> FAmw NAME F' <br /> SITE ADDRESS Ito S 1 <br /> Slroel Number Direction <br /> SImA Name ciw Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street N. <br /> CITY STATE ZIP <br /> PHONE IB E+T, APN# LAND USE APPLICATION# <br /> -o <br /> (2oq ) l�3-4386 j�3-3cr�-o8 Pa �-r <br /> r<f <br /> PHONE92 Ea,, BOS DISTRICT LDDAnDN CODE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M I'/r 41 V'�' CHECK H BILLING ADORESSM. <br /> P--G PHONE# En' <br /> BUSINESS NAME D t L-l.iJrJ Nt UjLPF-(`' 33¢—/�13 <br /> HOME or MAILING ADDRESS P- z1BO FAx#3aX (Z-A ) 3 -C7z3 <br /> Cm IAD I STATE CA ZIP "�e'-Z4 i <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MAN OTHER AUTHORIZED AGENT 13 <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 environmentaUsite 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: RECEVF <br /> COMMENTS: V1,21/63 gQ 041 It A rPf 18 [illlg <br /> d SAN JOAQUIN COUNTY <br /> /X/v9 6 U ENVIRONMENT <br /> A^ HEALTH DEPARTM[N-r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 72'v PIE: <br /> Fee Amount: d" Amount Paid ` l b , O b Payment Date 4 I d 0 g <br /> Payment Type �/ Invoice# Check# 1 5 g Received By: (\f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />