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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br />:I C -nl*7E,2CIQL f�ES/DENT/�L S OO 3�� � <br /> OWNER 10 PERATO R <br /> ❑ <br /> r e /G ���`L VA J A CHECK if BILLING ADDRESS <br /> FACILITY NAME t V�1 II <br /> O SS E TT/ S /t'Oe4FR V STOR <br /> SITE ADDRESS 14q,?-7 RFLGOTA R�. 2F-5eAGO/L/ 0/S 3Zo <br /> Street Number I Direction Street Name Ci zip cohe <br /> i <br /> HomE or MAILING ADDRESS (If Different from Site Address) 6 1914 R!Po 5 A R b. <br /> I Street Number Street Name <br />{ CITY STATE ZIP ,I <br /> FSC�CA&aAJ1S3-20 `1 <br /> 5 PHONE#1 EXT. APN# LAND USE APPLICATION# I <br /> ( ) �-36/g X07 - 34�d --Q3 IVIA <br /> PHONE#2 Exr. BOS DISTRICT LOCATIO CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dot'i <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME CPHONE# Ext.y � N <br /> —Fs € G© .su Z r �� Idv� <br /> HOME Or MAILING ADDRESS F. BOX 371-4 <br /> jJ FAX# / C <br /> CITY u/ STATE zip 5-3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this applition and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S E and FED laws. <br /> I APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY I BUSINESS OWNER El OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT <br /> I If,4PPLICANT is not the BILLING PARTY 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/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: /If/T A S 61 G L!D VI F A Y'yr� 7' <br /> COMMENTS: Z- <br /> /0,0 <br /> ,0 1� <br /> Fie <br /> S�'IOAQUI�C <br /> PARrrAf <br /> ACCEPTED BY: COL L)IS i EMPLOYEE#: t) 3�� DATE: z �b ry" <br /> ASSIGNED TO: S I p>� EMPLOYEE#: � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE; S2-n5' PI E:-2-(Q , <br /> Fee Amount- IfC? Amount Paid Oo.I G3 Payment Date 2 <br /> Payment Type v Invoice# Check# 'l$5 Received By: �F <br /> c�G II <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />