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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SC,HOOL �2 (P✓ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> L E E Aa 3G o 5 lLT <br /> FACILITY NAME <br /> QQ_ a OOL_5 <br /> SITE ADDRESS 3 (qq SJho5�2 ROAD FKACY - 304 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 31+0,9 SOI.(Tl-� KoST R <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 64A R�3 04 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (IFo ) 93 o - ss-310-4 o <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /'G <br /> CN L 5/�I� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> L A/ 0 e <br /> HOME or MAILING ADDRESS FAX# <br /> 6 . 37q4- ( ) <br /> CITY n L STATE eA ZIP 53�3/ <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 ENVIRONMF..NTAI. ALTA DEPARTMENT'hourly charges associated with this project <br /> or activity will be billed to me or my busines s identified on s form. <br /> I also certity that 1 have prepared this a plicatio and that a work to be performed will be done in accordance with all SAN JOAQt1IN <br /> COUNTY Ordinance Coder,Standards S'I ATt= d FEDF t.laws. <br /> APPLICANT'S SIGNATURE: D:tl"E: <br /> PROPERTY/BUSINESS OW\EOPERATOR/ AtiAGER ❑ OTHER AUTHORIZED AGF,ti7' �J�;^,L� IYn r�T„Z•:Z�_= <br /> IfAPP1,IC NT ' of the BII,LI:VG 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 FIEAL.'m DEPARTMF,N'r 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: SD/L S u/TAM G 17-VIWI T 6.0 E A <br /> COMMENTS: i No j <br /> AUG <br /> 142 <br /> SAN J gQUI <br /> HE T��NMENT �n,. <br /> ACCEPTED BY: Z_ EMPLOYEE#: DATE: e 13 d od o NT� <br /> ASSIGNED TO: A& EMPLOYEE#: DATE: 13 �O�U <br /> Date Service Completed (if already Completed): SERVICE CODE: c',d 3 P I E: awa <br /> Fee Amount: -l;�__ C) Amount Pai �a j'? Payment Date 04517'11'712- <br /> Payment Type Invoice# Check# ��S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />