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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G7QS Sty ftoh F4 01 <br /> O ER/OPERATOR <br /> G(///L. //�.,,/_0 CHECK If BILLING ADDRESS <br /> FACILITY <br /> c�Grev/-a✓1 L# 35 <br /> Z 3-zJ L y <br /> SITE ADDRESS/, w // �� /--onto _LG/ g521 C'l <br /> 330y Street Number Direction f(f Street Name �T, CIC Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> %075' <br /> Stree[Nember Street Name <br /> C54n Igl///L�L STATE <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> (656) 759-62f(8 07/20613 <br /> PHONE#2 EXT. BOS DISa04LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME( IK J r PHONE# ExT. <br /> Sf�UI?e r 6 759 6 Z X18 <br /> HOME Or MAILING ADDRESS FAX# <br /> cs r�e — !3/G (6 50 3N/-S W <br /> CITY �Gl a STATE CA ZIP 91ygp3 <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. -7 <br /> APPLICANT'S SIGNATURE: /��/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER I OTHER AUTHORIZED AGENT ❑ Vy<C /"r�'jIr-T�y <br /> I{APPLICANT Is not the BILLING PARTY,proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessmentnon <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is proviAa� <br /> my representative. �1 <br /> TYPE OF SERVICE REQUESTED: od J FD <br /> COMMENTS: 18 <br /> smdOq <br /> C�Qrt �'� c�c1J/l e� p IR°A n1, <br /> G HDfPM M Nl <br /> ACCEPTED BY: EMPLOYEE#: DATE: -7. lQ <br /> ASSIGNED TO: Rd a EMPLOYEE#: DATE: ^7 c;4Q <br /> Date Service Completed (if already Completed): LL SERVICE CODE: /PIE: D� <br /> Fee Amount: ` a0 Amount P;(LdD/S�, b Payment Date 7� <br /> Payment Type Invoice# Ch ck# - ��-/Y�-��g� RprelvedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />