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05/24/200E 08: 39 2094683 EHD PAGE 02 <br /> T . <br /> • T <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busir•ass or Property FACILITY <br /> IIDD 6 SERVICE REQUEST <br /> /n/57Y ee �yG4F/� <br /> F l��Ur� Y72rri✓-V�� <br /> OWNER/OPIcRATOR <br /> CHECK N BILLING ADDRESS ' <br /> FACILRYNAME C <br /> SrrEADI)RESS <br /> 7&4 amove Number DI a tlan ah el Z ceee <br /> HOME Or NIAiune ADDRESS (It DHfe t from Site Address) <br /> sb*et Nummr SLreel Name <br /> CITY STATE zip <br /> Pryy�E#1 En, APNS I.IWDUSEAPPLXIATION# <br /> .(r>i ) 270-5/ e3 <br /> PHONE#2 EM• ROS DisTmcT LocAnou CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR �, <br /> CHECK If nIWNG ADD0.FS <br /> BUSINESS NAIdE 2/AA) . v�I���v-'��� PHONE# • <br /> ill'-AL n/C 8• U�7G2U -- <br /> HomeorWi.inGADDRESS FAz# . <br /> 3v i�.9 /po,SA ,— 66) 6 <br /> Crry STATE �./I ZIP <br /> BILLING ,CKNONITEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge:that 0 site end/or project specific ENVIRONMENTAL HEALTH AEPARTMENT 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 /> APPLICAMPS SIGNATURE: •� &�, — . DATE! <br /> PROPERTY/AUSNTSs OWTICEl OPERATOR/MANAGER I7 OruEa AUTHORIZER AGruvT� `'/ l+�L SUZ <br /> ry'APPL7cANT 1s not the BILLING AaRTa proof of authorization to sign is requi a rule <br /> AUTHORIZATION TO RELEASE _ ORMATTON:When applicable,T,the owner or operator of the property located at the <br /> above site a ddress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information ;�the SAN JOAQUQd Cowne 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; / <br /> COMMENTS " I/V�/ G.L j�/1�//��"N/ //V (/%�"/•�''.:2. /�Gui/�ION/T/7J2/A/ <br /> MAY 2 6 200fi <br /> ACCEPTED BY: EMPLOYEE#: ?7 tD_ .' DAr CO <br /> ASSIGNED To; EMPLOYEE#: ,I3J� AN TH <br /> Date Service Completed (It already completed): SERVICE CODE: C P I E: <br /> Fee Amount Amount Paid — Payment Date — a� <br /> Payment Tyle invoice# Check# Rec Ived By: <br /> EHD 4"2.02'7 SR FORM(Golden Rod) <br /> REVISED 117 7/2003 <br />