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SAN JOAQUk.,.rOUNTY ENVIRONMENTAL HEALTI,.,,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S1LERVICE REQUEST# <br /> l yo / „ ,G_5 „ c)-7S <br /> OWNER/OPERATOR �1r-+ ■/'�/ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME - I �� <br /> \ V- ra <br /> SITEADDRESS 2 q o ( Main- �(/Y Y TyC I, <br /> J Street Number limction Street Name Zip Cotla D <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> StreH Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1EIT' APN# LAND USE APPLICATION# <br /> °d)OV $3H - la2o 213- D(oD-! 6 <br /> PHONE#2 EXT, BQS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ce Y Id Y J ` N Irn CHECK if BILLING ADDRESS <br /> BUSINESS NAME l PHONE# ExT. <br /> w -SI fC q1Vt0n t n qb - C40 �J <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY C 0-3 . Q STATE ct ZIP Q t l ' 6 G <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,ST {t/ d FE 5RAL laws. © d <br /> APPLICANT'S SIGNATURE: t_ DATE: vv�� <br /> am, I O G I O g <br /> PROPERTY/BusiNESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> JfAPPL/CANT is not the B/LL/NG 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 /> TYPE OF SERVICE REQUESTED: u.5 T- /r-6'7- -CGL T IV -1 <br /> COMMENTS: � 20 <br /> 06 <br /> SXN COUNTY <br /> EMARONiME TTAENT <br /> HEALTH DEPAR <br /> ACCEPTED BY: -,L t v .iJ�. EMPLOYEE#: >Z DATE: �V <br /> ASSIGNED TO: ✓� �j� ^I'7 EMPLOYEE#: 5-(i,•'12 DATE: Z <br /> Date Service Completed (If Iready completed): SERVICE CODE: r�,i P I E: <br /> Fee Amount: /S 00 Amount Paid ?J 1 S Payment Date <br /> Payment Type t,� Invoice# Check# ZZ 3 b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />