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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Vftqo <br /> OWNER/OPERATOR <br /> /—/A/^/4F— �SrAT GLC— CNECKifBILLINGAfIDRESSCI <br /> FACILITY NAME <br /> r.4 a iVI r <br /> SITE ADDRESS t/t/ 154M-e) A D • 77ZAL 9 -3 O <br /> 7 7 Street N,rt bel pirectioo Street Name Ci Zi Gude <br /> HOME or MAILING ADDRESS (if Different from Site Address) 6 4 re S gc4 p <br /> LJ M Street Number Street Name <br /> CITYq-R C STATE ^^ ZIP <br /> �-f'� 3 <br /> PHONE#1 ER• APN# 27�"O9O" O 9 LAND USE APPLICATION <br /> c ) 0-0&-0f,11 Zex7 PA - - 2z8 Z-7-f <br /> PHONE#2 ExT• BOS DISTRICTLOCATION CODE <br /> I i11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> UO/v f• / CHECK If BILLING ADDRESS <br /> BUSINESS NAME /I � /Y G IaHONtc# <br /> HOME or MAILING ADDRESS 3 FAx# (a <br /> . d • wok �7� I 1 6��-z <br /> CITY LPA STATE zip �� r <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 <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, S and FEDEWWS. <br /> APPLICANT'S SIGNATURE: za DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTH AU HORIZED AGENT L <br /> If APPLICANT is not the BILmNG PARTY proof Of authori tion to sign is required Title <br /> AUTHORIZATION TO RELEASE IN)F`OR.MATION: 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 is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:S4faFsf F 4011/rAlnlrtJ <br /> COMMENTS: RECEIVED <br /> NOV I:9 2004 <br /> SAN JOAQUIN COUNTY <br /> n 14PAI DEPAPT-h4pp-t <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATBG: <br /> ASSIGNED TO; EMPLOYEE#: qS:L DATE: `i <br /> r <br /> i Date Servicej:t� <br /> mpleted (if already completed): SERVICE C pE: 01 <br /> P!E: <br /> l Fee Amount: t Amount Paid Q^ Payment Data ( ( ) 1 <br /> I P <br /> Payment Type �/ Invoice# Check# Received By: klfl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />