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SAN JOAQI __OUNTY ENVIRONMENTAL HEALTI ZPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property :::: FACILITY ID# SERVICE REQUEST# <br /> G A-s STA-- O�J a46 y S' 00553rog <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Sak,� lam. <br /> SITE ADDRESS iL l}af <br /> Street NumEer Direction beet Name Cil Zi Code <br /> HOME Of MAILING ADDRESS (I1 Different from Site Address) S�fcS •a OL, <br /> StreetOONumper Vlb Slreel Name` <br /> CITY -Pt'e_"CUA,00 STATE n ZIP <br /> PHONE#1 �r EXT. APN # LAND USEAPPLICATION# `I <br /> PHONE#2 EXT. BOS DISTRICT <br /> LOCATION CQDE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MW- O "ka( " CHECK It BILLING ADDRESS <br /> BUSINESS NAME � Pe{HONE EaT. <br /> " ` avt* -" S Sfzu�c Tt,Lc . 6113-.b o'3 g <br /> HOME or MAILING DDREb S <br /> 8 G2L1:ttitn TAU-C-- FAx <br /> -�(3- 4,o (o <br /> CITY cn fU STATE CA Zip 9 `�t <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 /> 1 also certify that 1 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: Q'r10 /eL�O� <br /> PROPERTY/B USI NESS OWNER[I OrERATOR/MANAGER ❑ OT1iERAlITIiORIZEDACEN'I'Lb &ftti&i(-e S.T"`�(-er <br /> IfAPPLiC NTis not the BILLING PART)',proof of authorization to sign is required! Title <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/s'te assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anwd nyL � Tie time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Vq[&Je L7 cr�e((`Q-T A U e4A oa <br /> S1)� SCCe UN <br /> o r <br /> SPN�NPONM�P'(M� <br /> �jNpEPP <br /> N <br /> ACCEPTED BY: EMPLOYEE M OK3DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: . <br /> Fee Amount: -0 31 S c7 Z�) I Amount Paid ` 315' D'D payment Date 9/11 0 <br /> Payment Type Invoice# Check# -A?13 Received By: 2�L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />