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SAN .JOAQUIN000NTY ENVIRONMENTAL HEALTH DEQRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> R j 1. b�1 2 g1 SRao7�g� <br /> rodl- <br /> OWNERIOPERATOR u F � {� ,�`�ff <br /> —._S.LL L. )I " I m�r] �' (�" `� ,.._, _— - —- CHUCK If BIS-LING Af3[7RE55"`JJJ"`"'"' <br /> FACILITY NAME p n,r�OU (4 A` L'� <br /> SITE ADDRESS 1►'��t�J _* � ("k <br /> � �� POW TE� <br /> StreetNumtrer _?i„elction _ street Na me n City „_„ ZIPCada <br /> 11OME nr MAILING Ai,r!i,m (If Dilrer : :from Site Address) 41.ro-�- � o b Li W ✓L lJ� <br /> .,., __...,_ _...... ..___._.�. <br /> at Number <br /> clry 1 STAT,} ZII' q 3 (J <br /> PHONE#1 x Ext. APN# LAND GSE APPLICA730N <br /> (goT 64c) <br /> PHONE#Z EXT SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR O <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /+ PHONE# Ex-[, <br /> 'r �v 99 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP Sad <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`:;SIGNATURE: - - __ - � ____ DATE: <br /> PROPERTYI Bu:;!NFSS OWNER OPERATOR I MANAGER ❑ OTHER Au'FHOFtIZEi)AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title ` <br /> AUTHORIZATION TO RELEFSEINFORMATION: Wrlen applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authori'a the release of any and all results, geotechnical data and/or environmental/site assessment i!,formation <br /> to the SAN JOAQUIN COUNTY ,.NVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provk A to me or <br /> my representative. f <br /> TYPE OF SERVICE REQUESTED: Z 1 �J./� 1�y\ G Ir ��AYMENT <br /> COMMENTS: _..T RECEIVED <br /> i JUN'21 2616 <br /> SAN JOAQUIN COUNTY <br /> ENVIRORIlIINTAL <br /> TR OEPARTMIENT <br /> ACCEPTED BY: EMPLOYEE M DATE' rte, <br /> AsAsSIGNED TO: �friri�Q Lj/1( EMPLOYEE M DATE: ob- V <br /> ` I gate Service Completed (if already completed): <br /> Fee Amount: l�Ya Amount Paid Z C:) Pay ment rlate 4/20 b <br /> Payment Type Invoice# Check# 1 S Received By: <br /> . v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> d <br />