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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Props FACILITY ID# SERVICE REQUEST# <br /> �GVX-V 5R008 137 4- <br /> OWNER/OPERATOR <br /> Gc 1/L �� CGc <br /> FAcam NAME '� Z K- <br /> SITE�E$S I _ �G�'l•� GGf C G�.,u�l. Lj r� ��'1 9 <br /> HOME Or �i NO AD EBS (If Differs t m Site Address) <br /> rP nGK- 22 '12037C I <br /> CITY ..1_ � STATE <br /> SI cf,L �7"G6t ,C y <br /> PHONE#1 EXr• APN# LAND USE APPLICATION 0 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILL wry Armo■Rn <br /> BUSINESS NAME !, f r C mow} IG PHONE>� <br /> HOME or MAILING ADDRESS F �#[� I <br /> CITY SemLL Y `, STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 wil I be done in accordance with all SAN 1OAQUIN <br /> COUNTY Ordinance Codes,Standards,STA:TEand FE L laws. <br /> APPLICANT'S SIGNATURE: %/ DATE: I /� /! <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER 13 OTHER AUTHORIZED AGENT f 1 -"" <br /> IfAPPL/CANT isnot the RI r.ING/.IRTY proof of authorization to sign is required Tir1 r <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, / r <br /> TYPE OF SERVICE REQUESTED: e 04- <br /> COMMENTS: <br /> s-?' �� b <br /> ACCEPTED BY: r��s L p EMPLOYEE#: DATE: (O Zz <br /> ASSIGNED TO: EMPLOYEE#: DATE-, <br /> Date Service Completed (If already completed): SERVICE CODE: I E: <br /> -� P <br /> Fee Amount: `Z Amount Paid h� /J� �„ `l� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> P�os30S� <br />