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It <br />SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE <br />3 9—it Af — <br />e-90.2-2-1 <br />SRc)0 67 // q, <br />OWNER / OPWTOR _ <br />�C11EOK If BILLING ADDRESS E] <br />FACILITY NAME <br />ZIP �r C,' <br />SITE ADDRESS��' <br />/7 710 <br />, p - !�a/ i <br />'V ( <br />SERVICE CODE: 3 <br />PIE: 4y07 <br />9957.2KV <br />Street Number <br />D' tion <br />tee Name <br />Invoice # <br />C' <br />Zi <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />lelo <br />Street Number <br />Street Name <br />CITY �i �' A / <br />STATE ZIP <br />PHONE #1E.• <br />1,09) �fb e— 066 <br />APN # <br />065, --off <br />LAND USE APPLICATION # <br />6,Pa. <br />PHONE R Err. <br />BOS DISTRICT <br />LOCATION CODE <br />917 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/ /j f/LSI/ d--�� /����C <br />v , I •r 7 �/ ( <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE <br />E <br />HOME or MAILING ADDRESS C- / '0qve- <br />N <br />Ax # <br />61— So 2 P • <br />CITY �� f� STATE <br />ZIP �r C,' <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 <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 tha94 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FpW AI aws. , <br />lcL <br />APPLICANT'S SIGNATURE: DATE: 0 p� _ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT f® <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title CA46//✓Eef. <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: �/P/L G�/✓�i /��ie/X'///� trJ r ���•r/aL �/(/� �,r , <br />COMMENTS: AUT,; /�//C%i'✓ CT� TG✓U /" W ��OGI/✓� G��/�"� C^/Q <br />/i%Q%'✓i/cam'/n/l !✓�- CC l Q/✓ � � �✓�S/ ,s/!i� C� <br />�✓�� h/ lvk.�i y L.4-n/D�i�c . <br />Y/s// 3 - D ��u . �,� ,�. , ,� - s� - 3 A, - <br />ACCEPTED BY: ' ✓+9 <br />EMPLOYEE M 8 J <br />DATE: <br />o6'18113 <br />ASSIGNED TO: V,4 `-?j� A•A SURA 0T tVt, �� <br />i +� <br />EMPLOYEE M v� $ � <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 <br />PIE: 4y07 <br />Fee Amount: 3 7_S--=— <br />Amount Paid ?t <br />Payment Date <br />Payment Type S37— <br />Invoice # <br />Check # Gjj� <br />Received By: Zj <br />lit r <br />S�Hv 0 o 10 l tR <br />EHD 48-02-025 ��} � 2 � ".24 _SR FORM (Golden Rod) <br />REVISED 11/17/2003 9/,X$ t/L�e r✓c'-ds�o,� �/ � / _ <br />A/ z9 //3 — Odi--r V -4e -714 4•� ,"�--��h� G ._ 2,9 _ 3 A4 -j j M <br />tan o,0e U".a <br />