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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT it <br /> SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> # <br /> OWMER I OPERATOR CHECK K BILLING ADDRESS 1 <br /> FAciurY NAME <br /> SITE ADt]RESS �-?�(� S. ���'S � � <br /> Street Number c <br /> Diretion Street Nama Ci Zi Cade <br /> HOME Or MAILING ADDRESS (if Different from Site Address) "5-3&0) IV. 60a( i2D- <br /> Street Numher Street Name <br /> STATE GA ZIP <br /> CITY,, (�IND�iJ <br /> PHONE EXT, APN# LAND USE APPLICATION# <br /> Z30- 13 -PA - 0-7- Z%z <br /> PHaNE ExT- BOS DISTRICT LoCATZPWDE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK K BILLING ADDRESS D <br /> i t PHONE <br /> BUSINESS NAME �l 1�-ON i U�� � '3' .. 1 <br /> HoMI or MAiuNG ADDRESS FAX# <br /> `P, ZL°u0 <br /> CSN , I-W` STATE CA zip 9,5 Z4 I, <br /> authorized agent of same, <br /> business owner, operator or g <br /> d property or � P <br /> • T: I the undersi ne p rty , <br /> .:BILLING ACKNOWLEDGEMENT: II F <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]oAQuav <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: J <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I AIANAGER © OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tl f l e <br /> AUTHORIZATION 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 lOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. r <br /> TYPE OF SERVICE REQUESTED: Y��++t�`EN <br /> COMMENTS: R�V <br /> 7 <br /> $ <br /> . r CpUN� <br /> ' <br /> N <br /> ACCEPTED BY: EMPLOYEE#: 14 <br /> DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> Date Service Comple4(1fLr,,dy completed): SERVICE CODE: <br /> Fee Amount: Amount Paid q Payment Date 2� U <br /> Payment Typevoice# Check# G�tt� ck Received 8yN6r— , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />