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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 17:::ID# SERVICE REQUEST# <br /> Type of Business or Property 70 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> V © <br /> 'q-N <br /> FACILITY NAME <br /> LV 4-L0. lJ\7•./�Ct� <br /> SITEADDRESS <br /> L`o'-E\� Street Number Dlre n `w " Slre rno Chh 2i COEe <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (Zgf�\) ! 'Ail oo Ili <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR a CHECK If BILLING ADDRESS <br /> BUSINESS NAME P NE# Ezr. <br /> S�4- b23� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE <br /> e <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 /> COUNTS'Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'SSIGNATUY: \" 1,'- DATE: LiIz-L-1-3 <br /> —e <br /> PROPERTY/BUSDtlESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> 1fAPPLicANT is not the B/LLINGPARTP proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: cS <br /> COMMENTS: <br /> 3 �IbQ41&glYgQ <br /> `Mm3 <br /> Y <br /> (ice ga•ss IIT <br /> ACCEPTED BY: M EMPLOYEE#: 2-6 DATE: <br /> ASSIGNED TO: I�� ;- EMPLOYEE#: 4-0 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: �� PIE: 26o2 <br /> Fee Amount: 2 --� Amount Paid Payment Date 12-zll 3 <br /> Payment Type Invoice# Check# �a(7 Rece ved By: <br /> \ EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> i <br />