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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ST 56 ae EL S b a <br /> OWNER i OPERATOR <br /> 5T- 5H/I98C-L G'�U!l�Cy CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> S . 5'FfA(.z EG CfrGegcc1 <br /> SITE ADDRESS #ffI 45/1�Hr 1!;�7/4,E ,Q D. SToGAcTinA/ 95�i2 <br /> Street Number Direction 7 Street Name C& Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P" O '_ i3v x —74 oZ Street Number <br /> Street Name <br /> CITY STATE CA ZIP <br /> S Ta G KTv�! `I S.zG 7 <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (.2 of l 4v5'--,440'f 6S -.2619 -GS PA - to 00-24-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> yEs AI-a CHECK if BILLING ADDRESS <br /> BUSINESS NAME c' PHONE# Ext. <br /> Cl-HOME or MAILING ADDRESS FAX# <br /> P 0 • Sox 7q ( ) '1969-zs98 <br /> CITY � STATE ilrz[.Ocf� CA ZIP 53$ <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 TE and F L laws. <br /> APPLICANT'S SIGNATURE: DATES:/ �— �— <br /> PROPERTY/BUsmyss OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT LYS <br /> IfAPPLICANT is not the BILLING PARTY proof of uthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above si1:e address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 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: /`//TfZ 'c "ADI 50!G ra!rA sfA/ 5-rtf?X REV/E KIT <br /> ECEfV ED <br /> COMMENTS: lord' <br /> J�IJUN - 6 all <br /> /11- C='af�l7C, ('0 SAN JOAQUIN GOUNTY <br /> ENVIRONME 4TAL <br /> HEALTH DF-PAF TMENT <br /> ACCEPTED B(-( EMPLOYEE#: DATE: q r <br /> ASSIGNED TO: EMPLOYEE#: G�1f/l DATE; I f <br /> Date Service Completed (if already completed): SERVICElICooE• p i <br /> 5. <br /> Fee Amount: Amount Paid � ' D. D p Payment Date <br /> Payment Type t/ Invoice# Check# -I Y Received By: <br /> REVISED <br /> 11/1 SR FORM(Golden Rod) <br /> REVISED 11117!2003 <br />