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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EA 0000 Lo(-vL4 3Q00'9(Q05 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ( <br /> r ) I'di l s{, 1G R py. <br /> 1-201 Tit Street Number Direction iV L s�trelet Name / CIt Zip Code <br /> HOME or MAILING ADDRES (If Different from Site Address) <br /> 6 d Street Number Street Name <br /> CITYJ10 l� STATE ZIP -� O <br /> PHONE#1'�( Elrr. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex , BOS DISTRICT LOCATION CODE <br /> ( ) 916-43o-iii4z9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I ei Q I in <br /> w 1. [_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH NE En. <br /> Uma Sus InT(2 ) O-8 z <br /> HOME or MAILING ADDRESS FAx# <br /> CITY OCJ. STATE ZIP O <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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: VA,f I q oy •,I I X16 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILLING PARTP 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 environmentaVsite 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 /> A31 F- <br /> TYPE OF SERVICE REQUESTED: Foo NT <br /> COMMENTS: C Y 1 U n q O f O�6 Ivcu <br /> NOV 16 2O� <br /> V` SAN JOAQUIN COUNTY <br /> EM/IRONMENTAL <br /> N LTN DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: lV L <br /> Date Service Co pleted (if already completed): SERVICE CODE: 0(0 P/E: I 00'2 <br /> Fee Amount: \-o i Amount Paid ( Payment Date (P V12 <br /> Payment Type Invoice# c (p5��3 Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S <br /> ��ilo2S7S <br />