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• SAN JOAQUINOUNTY ENVIRONMENTAL HEALTHITIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY in# SERVICE REQUEST# <br /> To P b 32�� S✓�c <br /> OWNER/OPERATOR 4w - <br /> /_ AU a1±1 CHECK if BILLING ADDRESS <br /> FACILITY NAMEC�uI <br /> 132-SITE ADDRESS 3C5-r� l C� t�M Ivi E(?- Lam(t4� S1/ (Ci`0� Cis-Z.-Ucj <br /> Street Number Direction I Street Name city Zip Code <br /> HOr MAILING ADDRESS (If Different from Site Address) <br /> ME <br /> Lt I "rz�' s- Street Number Street Name <br /> CITY me STATEe. ZIP qelS.3 r' <br /> PHONE#1 tEXT. APN# LAND USE APPLICATION# <br /> C) �— �( 7� <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> - CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST/— CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> r -�� 1JZ o;� . G ( 416 /- 6 33 7 <br /> HOME or MAILING ADDRESSFAX# <br /> W I C C1,j 4"- Lam. r+v P- (Zd-; ) qG 3 Y Z <br /> CITY7-OC(CrC STATE/,4 ZIP Ci S-7 /6- <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, and FEDERAL laws. <br /> S TE <br /> APPLICANT'S SIGNATURE: -hUDATE: I Z-/Zal bS� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER U OTHER AUTHORIZED AGENT,I'��S�&"l Cu- <br /> If APPLicANT is not the BILLING 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 /> TYPE OF SERVICE REQUESTED: us—r VA <br /> p <br /> COMMENTS: l ECE,1 N7- <br /> U4 <br /> vTU4 G� WAA (44 ,w, ty""' F, �caf —14- •12, -4v , <br /> 4- g� �,.,,��.N��JCC Z � zoos <br /> H�CTN QIP"'V NT' <br /> ACCEPTED BY: EMPLOYEE#: DATE: C 2rW; <br /> ASSIGNED TO: _ EMPLOYEE#: �s DATE:1 2so <br /> S <br /> Date Service Completed (if already completed): I iffiqF9!V-- <br /> SERVICE CODE: I 1 E: <br /> Fee Amount: ^ -? Amount Paid a j-� 6b Payment Date �C <br /> Payment Type �I Invoice# Check# 3 S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />