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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7030 2 <br /> OWNER I OPERATOR <br /> a1 &s <br /> 'z- ICL" gtrvl'Ze CHECK if BILLING ADDRESS <br /> FACILITY NAME r..JI� <br /> 1` <br /> SITE ADDRESS . �S( qq'{w l L <br /> �Sp .S'.j,�E��. ? -" <br /> Street Number Direction Street Name Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) /'�%- A- �J�K k,• t JQrJ C k Ip <br /> Street Number Street Name <br /> CITY � G( STATE Gl� ZIP <br /> PHONE#1 W EM' APN# LAND USE APPLICATION# 7 to <br /> gYf� -9YfL r'ZR-rev �(3 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> nt c <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> P�.�IGc <br /> BUSINESS NAME G l //,�(p`/� PHONE# EXT' <br /> + ' 4 /( <br /> HOME or MAILING ADDRESS FAX# <br /> ►a ( os ) s- <br /> CITY �G t.-. STATE ZIP ps-LO� <br /> BILLING ACKNOWLEDGEMENT: 1, 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 or <br /> 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 TA and FED � <br /> APPLICANT'S SIGNATURE / DATE: lZ( l a7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER L9' OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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. p <br /> TYPE OF SERVICE REQUESTED: i�-5� t17�-C7F( <br /> COMMENTS: I -moi�y r TSP— CS -gesso v(S <br /> Pyy -C-U ti+G C ow¢✓ y ��/oGuf tef4 irM l Ry(It C on/N✓ Yf (o�fk PY7SY 20� <br /> (j,..(aH 2�/ �'S y`��t a,t�rCd '� �4�: `L•t�c�'1c s�^+��o"�` ,n Q-' ea V <br /> niv bP - 375 <br /> ACCEPTED BY: D Lt U�t �.d EMPLOYEE#: 3 DATE: /__ 2� G <br /> ASSIGNED TO: Vo^) �Lu� EMPLOYEE#: �3 j'7 DATE: `E 124107 <br /> Date Service Completed (if already completed): SERVICE CODE: C� O' PIE: <br /> Fee Amount: ads Amount Paid dg's-.CA) Payment Date 7� <br /> Payment Type ed_,LC t-r Invoice# CSI eak# Received By: <br /> ^ � S <br /> EHD 48-02-025 ;,SR FORM(Golden Rod) <br /> REVISED 11/17/2003p <br /> U <br />