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SAN JOAQL_ COUNTY ENVIRONMENTAL HEALT, EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SINESS NAME <br />SERVICE REQUEST # <br />PHONE#EXT. <br />-. <br />t773 <br />6"0&gs-03 <br />,OWNER./ OPERATOR <br />,I <br />rot <br />'4 <br />HOME or MAILING ADDRESSFAJ(# <br />+t S <br />CHECK If BILLING ADDRESS <br />n <br />W `I : O v,A I' L U . L� C13 <br />ASSIGNED TO: G �� GC (� Gj <br />oI� ve <br />FACILITY NAME <br />(7f�) <br />ITE ADDRESS <br />1 ',-))Street <br />I <br />ZIP <br />Gv �C Jcf <br />S—`7j�ts{n� <br />-Zip <br />� � Number <br />Direction <br />Check # <br />Street N <br />Code <br />E or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />C"—y <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />/ <br />LAND USE APPLICATION # <br />( ) <br />C4 (a 0 10 1 <br />40NE#2 EXT. <br />BOS DISTRICT <br />LOCATIONCODE <br />I ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR d ( �� �,� ��(J I (�Y <br />CHECK If BILLING ADDRESS <br />SINESS NAME <br />PHONE#EXT. <br />-. <br />N' o <br />0 P <br />ENVIROMENTAL <br />LA A.�—DEPA'44;111111=111'* <br />rot <br />'4 <br />HOME or MAILING ADDRESSFAJ(# <br />+t S <br />L <br />ASSIGNED TO: G �� GC (� Gj <br />oI� ve <br />DATE: <br />(7f�) <br />ITy V':t P <br />U L <br />STATE n <br />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 Ordi Sc Codes, Standards, STATE and FEDERAL la S� <br />APP CANT'S IGNATURE: ATE: <br />PROPERTY/ BUSINESS OWNER❑ OPE OR/MANAGER ❑" OTHER AUTHORIZED AGENTP iP LS <br />If APPLICANT is not the B ING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE i1 FORMATION: 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: LA_ C' vz'tV\a tj <br />COMMENTS: <br />PAYMENT <br />RECEIVE[) <br />NOV 15 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />LA A.�—DEPA'44;111111=111'* <br />ACCEPTED BY: <br />EMPLOYEE #: DATE: t i1. y— <br />L <br />ASSIGNED TO: G �� GC (� Gj <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Ol <br />P I E: <br />Fee Amount: 7 74--;, J <br />Amount Paid <br />Payment Date �( 5 <br />Payment Type �� <br />Invoice # <br />Check # <br />Re eived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />