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SAN JOAQUIN COUNTY ENVIRONMENTAI.IIEALTH DEPARTMENT <br /> SERVICE. REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SNQ:o _DDl�11lD <br /> OWNER I OPERATOR <br /> � `KS CHECK If BILLING AOORESSO <br /> N <br /> FACILITY NAME <br /> rJu t -- <br /> SITEADDRESS - -- <br /> a,r 4nre a�a-- Ala - tr _ <br /> 91roal Nemtwr mromm� Slreal N... God. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) *�700 <br /> a.-..a.. st-Okinne <br /> CITY STATE LP <br /> a <br /> PHONE#1 Per. APN 0 LAND USE APPLICATION# <br /> PHONE#2 Em• 1305 DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQLESTOR CHECK HOWM&OUJa <br /> S6 K <br /> BUSINESS NAME ./ ^ PHONE# �' <br /> HOME or MAILING ADDRESS FA%# <br /> 1 ) <br /> CITY Gm 4"E: STATE /f w zip O 9 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 will be done in accordance with all SAN JOAQUIN <br /> COUNTY ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 9j•�/r - . <br /> PROPERTY/13USINESSOWNER❑ 0PERATI M ACFH b OTHER AUTHORIZEDACENT� AF 60rL TA`✓AK'( <br /> IfAPFUC4NT is not the B/LLhya PARFY proof ofauthorizallon to sign is required Title <br /> AUTHORIZATI0N 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 IF available and at the same time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �MAer f/#iR4WtAtFAPP Of t_XiSTf/✓f. 4 T�W#dl�CS. IZiMMACV <br /> �ru.lAro►ZKl ssyvs� Geat+a;n, v-nverN�s, d- ,ouazvftur�" <br /> ACCEPTED BY: {"1r It e S W EMPLOYEE#: DATE: r 20) <br /> ASSIGNED TO: EMPLOYEE#: DATE: 3 <br /> Date Service Completed (It already completed): SERVICE CODE: S-yaj PIE: t& O/ <br /> Fee Amount: !.F C(p Amount Paid Payment Date <br /> Payment Type I v \ r0 i, Check# Received By: / .2 <br /> EMD 48-02-025 r� \ 11G �j - r -� SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> r n C&4 - <br />