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SERVICE REQUEST <br /> Type of Business or Property FACILITY IDN SERVICE REQUEST N <br /> 5K-C)1) 1' 3-s <br /> OWNER/ OPERATOR <br /> p-pN McitAkN 15 CHECK Hf31LLINGADDRESS El <br /> FACILITY NAME fzj M q( N"E Pr(LD S <br /> SITE ADDRESS l(A( 2-1 LI M-f-T`/ 12D . /�t/lM1Pp <br /> street Nu r 21 Cody <br /> HOME Or MAILING ADDRESS (H Different from Site <br /> Slroel NumberStmot Nam, <br /> CITY R( P ptj STATE C-P, ZIP 615-3(0 LO <br /> PRONE#1 APN f LAND USE APPUCATM tr <br /> ( w1i 5^11`1 - ll8lo C)01-o50 -0i eft - lloo038 <br /> PHONE N2 en. 803 DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCG O CNECKff_ __ww„cc13 <br /> !,O 7 B 1�'A <br /> !! ry <br /> BUSINESS NAMEPHMN Em <br /> LIJE: opgG- C�EI�EJNIf�NMEr.1T1°t"L 2oq 3�1-03�r <br /> HOME or MAILING ADDRESS40qW• OMC- �T• FAAN <br /> (Zoa ) 3tP`i -033 <br /> CITY LfA I STATE C.Pt ZIP q mayq O <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 wdl be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY ordinance Codes,Standar and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t-')- Dsr> : I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 01 HER AUTHORIZED AGENT❑ <br /> lfAPPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: IeEVI C W 50i t•- SV ITA F i L-1-T' s( S`rvA y <br /> COMMENTS: �A ENE <br /> -79r aU N COON <br /> `` JC 'tAm A ENSU" <br /> SAN '/`EIC <br /> ACCEPTED BY: V C_ ( l/E( LDS EMPLOYEE S: O '3 Z / DATE: 9 Z ( <br /> ASSIGNED TO: T- S C G- -�, EMPLOYEE M: SS q DATE: '5 Z Lel/ <br /> Date Service Completed (If already completed): SERvicECom: S-2 Z PIE: 2- <br /> Fee Amount: - -2-5-() , cIi j Amount Paid 4•;ZSo Payment Date j u�II <br /> Payment Type { E c� Invoice 0 Ctnek 8 1 Lf g' _� Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />