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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIIJDX ARTMENT <br /> SERVTCE­REQUEST .� <br /> r , SERVICE REQUEST# <br /> Type of Business or Property FAGl IjY•D <br /> Shoo 4 `13q `f <br /> OWNER/ OPERATOR CHECK It BILLINGADDRESS❑ <br /> !Rw A u 2URA.JS <br /> FACILITY NAME V/SIA LVI-+A V1n1✓(�I n/tD St <br /> [StTT,EDDRESS v MA LRoAb / t_IQC(L( jStreet Number DirectionStreet Name CaZi Code <br /> or MAILING ADDRESS (if Different from Site Address) /� C R y�L, 2 0A Slr¢et Number � Same STATE ^ ZIP /_ 2 'ONE#1 EXT. APN# LAND USE P A N# S <br /> PHONE#2 E"T BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t—) _ CHECK If BILLING ADDRESS <br /> AR�vS /, # EX <br /> , I�oI<1JLh <br /> HONE <br /> P <br /> BUSINESS NAME _ <br /> til scl-I AticM�s 2 _i Gr <br /> HOME Or MAILING ADDRESS FAX# <br /> �S�Z 1IGRJz � D 2��136 -�6b <br /> CITY L_ �a STATE ZIP Z C../ <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 and FEDERAL laws— <br /> APPLICANT'S SIGNATURE: /% Z— DATE: Z-1� 9 Co <br /> PROPERTY/BUSINESS OWNEI�LII OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BLLLING 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. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: (✓ <br /> COMMENTS: JUL 13 Zoos <br /> SANJOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: <br /> EMPLOYEE#: 3t DATE: � 3 <br /> EMPLOYEE#: DATE: -7 Q(o <br /> ASSIGNED TO: <br /> SERVICE CODE: PIE: <br /> Date Service Completed (if already completed): 2 <br /> Fee Amount: O !r Amount Paid . (�ll. Payment Date (I 3 <br /> Payment Type S invoice <br /> Check# Received By: (5 <br /> " SSR FORM(66(den Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />