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SAN JOAQUU4 COUNTY ENVIRONMENTALREALTIIDEPARTMENT <br /> SERVICE REQUEST x <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> owNE 1 OPERATOR 0 -(- S-� k�t a ►� <br /> CHECK if BILLING ADDRESS <br /> FACiLmNAME /t-pu-ir Crf-'`6a t C�1re-ayy� 4— ��� cs�`t �l /'1 <br /> SITE ADDRESS ��.} d �-f ire M p V1 5-to c k-{z C A <br /> Street Number Direction Street Name city ZIp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT JLOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR-1-�Gtr•[ S e e 1 n el <br /> CHECK If BILLING A6t)RI=5 <br /> BUSINESS NAME feel L �e1� PHONE# SE"r' <br /> fima,n zgol lf-77-4 <br /> J <br /> HOME Or MAILING ADDRESS / Fax# <br /> I3J✓ ( ) <br /> CITY S'-fd C k t n-' STATE GA Zip 13—z <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 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BVSINFSS OWNER El OPERATOR I MANAGER ❑ OTHFR AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILIJNG PARTY,,proof of authorization to sign is required Title <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 sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C�s'u A4 (� <br /> COMMENTS: nn � <br /> Pry Cusf'e.0 - riAe- Cit- � i5,Ory 1")/ a.f1 orpu- r- -r <br /> 9�M,�a�i <br /> ACCEPTED BY: EMPLOYEE#: � f/ DATE: <br /> ASSIGNED TO. /e �y� ��� EMPLOYEE#: `� !J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P f E: <br /> i J <br /> Fee Amount: p0 Vol Amount Paid.% _.�. Payment Date <br /> Payment Type Invoice# f 7 i r Check# IReceived By: <br /> L.; I <br /> EHI]48-02-025 A� , / SR FOI [N (GoEdenf2od) <br /> REVISED 11111712003 <br /> �G r <br />