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SAN JOAQUIN "OUNTY ENVIRONMENTAL HEALTYr`IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> CHECK If BELLING ADDRESS❑ <br /> FACILITY NAME A rG <br /> SITE ADDRESS 1�d S � A t�\S O n ��Q C <br /> Street Number Direction V� Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4 C e&-N <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> \�� LAO(z3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> dZ0- G <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �( CV, / <br /> \ CHECK If BILLING ADDRESS <br /> �G q <br /> BUSINESS NAMEPHONE# ExT' <br /> -n-AA ON A,< <QN 3( 9 - ZZZ- <br /> HOME OP MAILING ADDRESS FAX# <br /> 1 4 u (310 ) 9- 'LZ-Z <br /> CITY h C3 4 STATE Q$ ZIP <br /> BILLING ACKNO EDGEMENT: 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, ATE and F DERAL laws. / <br /> APPLICANT'S SIGNAT DATE: ((0 l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTpr i4 a1P_t + <br /> If APPLICANT is not the BILLING 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 same time it is <br /> provided to me or my representative. n <br /> TYPE OF SERVICE REQUESTED: <br /> �slREQUESTED: w � � nC -- 4-£ <br /> COMMENTS: 1t'S�k ,c � \ a � <br /> � <br /> F <br /> GA co � <br /> a , , e � OCT <br /> � �y ,J -joova 2007r <br /> � <br /> y ti RONIN COUN77' <br /> DATE: A <br /> ACCEPTED BY: EMPLOYEE#: ('j ?,Z.-( 10 !f WT <br /> ASSIGNED TO: u Ic-.,J EMPLOYEE#: �(,, (�_ DATE: 10 S/Cj <br /> Date Service Completed if already completed): SERVICE CODE: PIE: 2--Sb <br /> Fee Amount: 9--cq q.L7V Amount Paid oo Payment Date 1 510 <br /> Payment Type d/ Invoice# Check# 3 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 / <br />