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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/-,e2/1" <br />FACILITY ID" SERVICE REQUEST # i <br />OwNEV OPERATOR - <br />h CHECK if BILLING ADDRESS <br />FACILITY NAME . , <br />SITE ADDRESS c,72f <br />s7) <br />Street Number Direction <br />t 4t34/4,-/i (44 <br />et Name <br />p Le-r,„iTee. <br />City <br />9 <br />ZiD Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />4#1411 4(4C% - <br />'llei cf- 6Sc63 .. <br />CITY STATE <br />PHONE #1 Err. <br />ow g'e-- 7p 3 I <br />APN # I LAND USE <br />AAA/ "" PHONE #2 Exr. f i <br />. <br />( ) II <br />BOS Div <br />CONTRACTOR / SERVICE RE UES' <br />REQUESTOR <br />_ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME i( It. PHONE # Err. <br />HOME or MAILIft10 ADDRESS / , / ff_.1, at <br />CITY <br />( <br />FAX # <br />) <br />STATE/ 1 ZIP <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, STAT and F ERAL laws. <br />APPLICANT'S SIGNATURE: ta <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT (36r44xt., <br /> <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 />P4 ), TYPE OF SERVICE REQUESTED: LThr-itet-t_ f rn titi_e_ei.,,x)c.66.e6v.i..) -V—ifr2eC—, ifi' A <br />COMMENTS:C 'd KtpcittA / 21-rnoci-e/ P1 A-41 4e _ tez-4-e4e) mg. e # X - - c12,Yirc___ E2 04Q , I <br />w7.4f, <br />ACCEPTED BY: c5 (TA EMPLOYEE #: - DATE: ,2_63 i 5. <br />ASSIGNED TO: L i ruutiLizo EMPLOYEE #: DATE: Ap / S--... <br />Date Service Completed (if already completed): SERVICE CODE: a..3., P i E: <br />Fee Amount: ), i.e 0 Amount Pai9-26,0. 6 2.3 Payment Date - <br />Payment Payment Type 7- Invoice # .7 7- Check # 42 gi ; , • <br /> <br />1 •'L i 1 - <br />- R c•flveci : aiityl----' <br />- I , • <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />4R/116RM (Golden Rod) <br />DATE: