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SAN JOAN COUNTY ENVIRONMENTAL HEALTt`�'JEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property _ <br />/ � 13115 2 <br />FACI77D��— <br />SERVICE REQUEST # <br />/ //Jx <br />[�D o o <br />�/Zotl) 63 <br />OPERATOR <br />ZIP O� / <br />/OyW�N�Et [Ri <br />!� / / <br />(%GV S \ �C ��/C /9 (,� a /J�` , ( <br />('�/ <br />C 7r4 7Q CHECK if BILLING ADDRESSL,/ <br />J <br />FACILITY NAME <br />1J04�G .J <br />L �5� Si7" <br />SITE ADDRESS 1533 G/�,l ('� �j rO CKTpnJ CJ SLOS <br />L <br />Jtre. <br />Street Number i <br />CII oEs <br />HOME Or MAILING ADDRESS (If Dihfferreent from Site Address) T l O / pL p 6L EN (/ice j s v�i»Tc <br />Z' <br />•`" <br />CITY <br />`i SSIIMI Number int Namw� <br />� _ _ <br />I T� <br />l CL '1/Vol' 'TATE <br />60 CZ'P <br />PHONE #1 /7 En. APN # <br />(SN VO1'9 <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />( w) a >S- solq <br />BOIS DISTRICT <br />LOCATION CODE <br />REQUESTOR12AotJ�_ <br />I' <br />�� <br />CHECK If BILLING ADORES2ff <br />BUSINESS NAME/ / ��� PHONE# <br />�� <br />D 5, Err <br />/ <br />HOME Or MAILING ADDRESS <br />FAX# <br />ow s/,1 ( , <br />9C 66 S <br />% <br />CITY / Gme / / LG/rd / s STATE <br />Oil I MR^ Anvue�rm � <br />ZIP O� / <br />��...,..� r,..ra.www"1rvomr N c 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 Or <br />activity will be billed to me or my business as identified on this form. <br />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-afid FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE. <br />PROPERTY/BUSINESS OWNER1 , OPERATO ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />/f APPLICANT IS nOJrtt]e BILLING ARTY proof Of authorization to sign Is required Tlfre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It is available and at the same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />PMPNT <br />COMMENTS: <br />p /� y <br />RECEIVEI,#'/ <br />47�v <br />DEC 0 9.2x13 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEP WITMENr <br />ACCEPTED BY: t;\ jv1 n <br />Jv'I,�, <br />EMPLOYEE #: rL /` o DATE: 1-2, lei <br />C' 1 I <br />ASSIGNED TO: 1 LV b. <br />J Y <br />EMPLOYEE #: <br />y g�7 DATE: <br />Date Service CompletA (if already e plated): <br />$ERVCECODE: PtE;Z�G� <br />Fee Amount: ©0 Chi Amount Paid <br />3U ' O G/U Payment Date <br />PaymentType / <br />Invoice # <br />Check # <br />ilveBy: <br />07117108 D 0-025 SR FORM (Golden Rod) <br />