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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ <br />Pv 4,,e r' <br />\l <br />FACILITY ID # <br />SERVICE REQUEST # <br />rtet~t <<,, ?cktos act t (f'w-'-J) <br />/ t �`� <br />! Z 'r`stD" prc� �,�va� <br />u�-r <br />PHONE# <br />205 <br />5 R C e g4 U R <br />OWNER/ OPERATOR <br />Oi l <br />�i�I✓e <br />12— <br />ct � / / CHECK If BILLING ADDRESS <br />(v<t t s L�Te <br />r Wa _j„! i�-i LLL <br />a� , <br />CITY ,k-6 <br />FACILA NAM <br />STATE 64 <br />ZIP O 0 <br />SITE ADDRESS l S 3 i YIJT"'ne <br />ACCEPTED BY: <br />120 -<J <br />EMPLOYEE M <br />' <br />5-2i 2 <br />Street Numbor <br />Direction <br />Street Name <br />I <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from <br />Site Address) / 2O <br />L <br />N , �T/Yivt �•}ry�G,T� <br />Fee Amount: <br />Street Number <br />Street Name <br />CITY f GI +-Dvl _ <br />`}'rT} f4, t <br />Payment Date 1 Z 2 - <br />STATE f.4 ZIP J 7-a 7- <br />PHONE#t ExT <br />(toy) `7/90 -2(050 <br />APN # <br />07-57- /90 -3 <br />1 23 Z <br />LAND USE APPLICATION # <br />4-J ziool3g <br />PHONE#2 EXr• <br />(261) (0,34 - 25'-2 S' <br />BOS DISTRICTLOCATION <br />`y <br />11 <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />he vt 411 <br />/ <br />Pv 4,,e r' <br />\l <br />vr►d N, �-$ `,an e( SYG Irl Fa t <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME q / �f <br />/ t �`� <br />! Z 'r`stD" prc� �,�va� <br />u�-r <br />PHONE# <br />205 <br />EXT. <br />�jgo- 2G; D <br />HOME or MAILING ADDRESS <br />IZ63 <br />FAX # <br />(2o� ) <br />1-M6 -2-4,441 <br />CITY ,k-6 <br />ENVIRONMEN <br />STATE 64 <br />ZIP O 0 <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 Ine 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 STATE and FEDERAL laws. �/ v <br />� � i'�'+'`aSr"j �tAt.«�t/ �•- N� � u/� 12 -LA <br />APPLICANT'S SIGNATURE: I r i?r lost 4 c—}- DATE: / <br />PROPERTY / BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT � �ir! S/ere <br />IfAPPLICA 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 enviromnentaVsite 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: leetifGhJ C'0. .'bele <br />Jdi l Jv")q bitlt <br />vr►d N, �-$ `,an e( SYG Irl Fa t <br />COMMENTS: <br />KEGEN1 <br />ITEC 17 <br />SAN JOAQUIN C <br />ENVIRONMEN <br />HEALTH SPAR <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: d <br />211 <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service dompleted (if already completed): <br />SERVICE CODE: <br />1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date 1 Z 2 - <br />Payment Type <br />Invoice # <br />C ck #3 ,, <br />1 23 Z <br />I Received By: <br />/ <br />EHD 48-02-025 ZI / (// 2—D2-1SR FORM (Golden Rad) <br />REVISED 11/17/2003 <br />T <br />321 <br />UNTY <br />AL <br />ENT <br />