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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L 5(Z00 (, Y037 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS IZgl5 �/ ✓ALP/Cp 7/ZACY 9 377 <br /> SVeel Number Direction Street Name cl " Me Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> F. P. BL>K 3CZ7 Street Number Street Nem. <br /> CITY STATE ZIP <br /> Aq C4 '?5379-0327 <br /> PHONE 91 E.T. APN# LAND USE PPLICATION# <br /> V07) _ o -06,9-// � - oozz� (C > <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR DON <br /> C CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ETT' <br /> HOME Or MAILING ADDRESS FAA# <br /> 1 1fi-Z5 <br /> CITY QL STATE ZIPI L4 `,? <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 ap 'cation and lha C work to be performed will be done in accordance with all SAN JOAQI IIN <br /> COUNTY Ordinance Codes,Standards, TE and FIE 'V laws. <br /> APPLICANT'S SIGNATURE: DATE: 12— <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/?' NAGER ❑ HER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY,proof of aurh izahan l0 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: Niro _ LOAD/A/ $vIG uirAffa s 6(A/ PAYMENT <br /> RE <br /> tDM��j2� i1,yY1�, Z� ii 1 I 6V DECc s 20» <br /> II ) N a►kt7f Q sAN uOAauN courrn <br /> l ��� „IlG K_ � H�TMpEARTMENT <br /> ACCEPTED BY: m L I V E r ZA EMPLOYEE#: O•.j DATE: <br /> ASSIGNED TO: —ir-4S( 0,40 t.L L-as EMPLOYEE#: 1404-6- DATE: / t //-Cl/ <br /> Date Service Completed (B already completed): SERVICE CODE: S2S P I E: Z(ep 2 <br /> Fee Amount: 6 2-5- CrV Amount Paid �ZS C70 Payment Date <br /> Payment Type Invoice# Check# 3 Z/ Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />