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SAN JOAQUIN,�IUNTY ENVIRONMENTAL HEALTH D�tRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC EQUEST# <br /> C N& STPgTL0 N S ROO WIT <br /> OWNER/OPERATOR ' r O J Ce <br /> CHECK If BILLING ADORESSO <br /> FACILITY NAME <br /> SITE ADDRESS as-6�1�'C+ We <br /> Street Number Directlon HClStreet Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#P Er. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> M0. We,I�-fnVi,�Lv( CHECK If BILLING ADDRESS <br /> BUSINESS NAME �. ` �. ,_ C Sj„�. ^YuC. i.°r ala E <br /> HOME Or MAILING`A§p8FESS -r�-TLQyt J L'C .Jr FAX# <br /> 4k0 o Rif Z (401) a13 (0 0.1(p <br /> CITY S'aAA STATE Ck ZIP 9 0/�3, <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:1, V. DATE: 31 el oq <br /> PROPERTY/BUSINESS OWNER❑ Oi�tnnf' if'RKYO' AGER. �sAutaomzED AGENT IP CA NA�(1d1:lCE QTCt ✓ <br /> IfAPP7[GwT is not the B/LLmc PAR 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. <br /> TYPE OF SERVICE REQUESTED: `\ A <br /> t r <br /> COMMENTS: SS? V,It I( `D ll,lt(,V\C. Ct�S tClll '�-+r�c.V y�C.� gZYuLn I.JIVCakC d"Lk 1" ED <br /> MAY 2 L c006 <br /> SAN JOAOI INCOUNTM <br /> AL <br /> __,.rHU pggTMENT <br /> ACCEPTED BY: EMPLOYEE#: S DATE: rJV-rte, <br /> ASSIGNED TO: EMPLOYEE#: 1� DATE: ` Z�CJ'-gG � <br /> Date Service Completed (If already completed): - - _ SERVICE CODE: -l� PIE::- Z30p <br /> Fee Amount: a✓� Amount,Paid Payment Date YNO b <br /> Payment Type invoice# Check# '��-� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />