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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# pSERVICE REQUESiT# <br /> RaRq L RES/AEN / 5j` 00074301 t <br /> OWNER/OPERATOR <br /> MIZ. E A 4 VA le E E= <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �'�Cl�G S SlAo 7-4- ,4G 9'5370 <br /> Street Number Direction Street Name C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> , Street Number Street Name <br /> CITYSTATE, ZIP <br /> AAI:X CIA <br /> PHONE#7 EZT' APN# LAND USE APPLICATION# <br /> a ) 014-,1575-5 X39- 190 ,27 - a -;-kl& <br /> PHONE#2 EZT• B DISTRICT LOCATION DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ON CsE CHECK If BILLING ADDRESS <br /> BUSINESS NAME /1 G E Nuc 'y PHONE# ` ' O EXT. <br /> HOME or MAILING ADDRESS �� J <br /> IZ LFA%# <br /> CITV � L C� STATE ZIP fS: g <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 preparedthis applica' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT n FEDERAL S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT JU <br /> If APPLICANT is not the BILLING PARTY,Proof Of authorization f0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properly located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /VIZZArE <br /> n+ f//➢0N/i/ ityunP f//SEc NsAyA7Ec:IVECOMMENTS: (Re ved Suty in <br /> ft ad on VII lyr <br /> ) <br /> UG <br /> 4Jafta130lo/ 04 20p <br /> / -5c <br /> N.y OA <br /> g�St/P/ go <br /> aSe523 '+Ea�'Act <br /> ��Ukry <br /> Io%v t9 3OmtH y/e: Af P-r <br /> 70/e s/ry 40m, till . se 6'23 <br /> ACCEPTED BY: Il EMPLOYEE#: DATE: <br /> ASSIGNED TO: /1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Y PIE: <br /> Fee Amount: ZO Amount Paid y-- Payment Date <br /> Payment Type /,./ ; Invoice# Check# _ Received By: <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />