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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -4ce 6'1-16M S&101 T— <br /> OWNER/OPERATOR ��// <br /> � tf /C1flC fit'vee-,� CHECK If BILLING ADDRESS� <br /> FACILITY NAME /MC4�1 6 Cr�2� <br /> SITE ADDRESS U0 s 1 C t irlan Lehr° P X5-33 t; <br /> Street Number Direction 1 t treet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3� °1 ��� 9q r7C,trrr A� . <br /> Street Number Street Name <br /> CITY ��` ST,�4TF 15-3 <br /> J ZIP 7 5—C <br /> PHONE#1 `+ li E.T. APN# LAND.U�USE APPLICATION# / / <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> (j r/(.t/I C> �1V�C�l CHECK If BILLING ADDRESS <br /> BUSINESS NAMEmck/1 t ,rt P lei <br /> EXT. <br /> HOME or MAILING ADDRESSFAX# <br /> 3/I SCz,� /1 56 r <br /> CITY Od-J2St� STATECA ZIP '75— 3 J <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 1 have prepared this application and that the work to be performe one in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA DERAL laws. <br /> OPPLICANT'S SIGNATURE: DATE; 0-3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> /fAPPLlCANT is not the BILLING PARTY,proofoauthorization 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 anat the same time it is <br /> provided to me or my representative. �cc <br /> TYPE OF SERVICE REQUESTED: CC r <br /> COMMENTS: <br /> �wv MqR 1 y 20 <br /> h F.ORc ?O <br /> �CtHQDp� 4N�y, <br /> FNr <br /> ACCEPTED BY:�� /��Q '] EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ \ Get L�/c EMPLOYEE#: DATE: <br /> Date Service Completed -(if already completed): SERVICE CODE: U(-2 P/E: <br /> Fee Amount: Amount Paid �a:-- Payment Date <br /> Payment Type ' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> l�r0`5 3-7+1 <br />