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GV C ,T tv T U I --t 1Z Yl1 �P 10 z <br /> p>�,NerSAN JOAQUIN-zbUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> "WR— ;Lf Z O SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> te" BaitLd"0 �� l5 500&13y1 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> rCLNLet �Scvbav- <br /> FACILITY NAME or <br /> k F�r i+a Q il�f� -:Ck <br /> SITE ADDRESS -�.- t7 S�m t �Q�-}-e�a q•5 3--3 <br /> Stree Number beat Ne a ' I_ <br /> HOME Dr AILIN ADDRESS (If Different from Site Address) t4-U Yb <br /> p(' G{- <br /> �• Street Number treet Name <br /> CITY STATE ZIP '"I.S <br /> o C <br /> 304 <br /> PHONE#1 Exr' # <br /> APN# LAND USE APPLICATION <br /> WWW t + Ft14-3��- <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Fu G� c�bct H CKH BILLING AoR <br /> �`/ rJG <br /> BUSINESS NAME PHONE# <br /> Care }Jek5 DLv)Jev <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Li N d erJ STATE LP R 523 <br /> BILLING A KNOWL•EDGEMENT: I, the undersigned property or business owner, operatorr e, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charge t ct <br /> or activity will be billed to me or my business as identified on this form. <br /> OCT � �I LE/Q}r�nj� <br /> I also certify that I have prepared this application and that the work to be performed will be done in a€ dance wI h a I OROAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL law . �IRONItVN-1 HEALTH <br /> APPLICANT'SSIGNATURF: ?µ /i- _ — DATE: / BER,4 Es R <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CA is not the BILLING PARTY proojojaalliorizalion to sigh is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. tI- �p <br /> TYPE OF SERVICE REQUESTED: �k-p( y21 <br /> / I <br /> COMMENTS: Y T o r <br /> N�j J rrn= Qa lL z�xJO, OCT 2 9 2010 <br /> SAN 3ORONMEOUNTY <br /> NTAL <br /> ACCEPTED BY: ® r—wk , EMPLOYEE M <br /> ASSIGNED TO: EMPLOYEE M ��0 - DATE:L i U '� <br /> Date Service Completed (if already completed): SERVICE CODE: P1 : 2-3 Qd <br /> Fee Amount: �p Amount Pal d3 Payment Date O a <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />