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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> �of� S,��G—V I N i✓rtT`I - <br /> FASILITY NAME SptN GU 1 N�TT I f N V�STMEr�T`I l C <br /> SITE ADDRESS ,(�C� ` �S{�LuN �Cl�Ld TY} 'Y�'Ibt I^' "�1}r-� <br /> eet Numher Direction Street Name Ci Zi Code <br /> Str <br /> DOME or MAILING ADDRESS (If Different from Site Address) r�6 38 Go/jp2npOt-/S <br /> Street Number Street Name <br /> CITY STATE CA ZIP L? Z"3 0 <br /> LINnE�j <br /> PHGNE#1 EXT. APN 0 LAND USE APPLICATION# <br /> &0-� - 1 167 --130 �° ®6 r71 CsA <br /> PHONER Exr. BOS DISTRICT LOGATIO CCDDE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REOUESTOR + CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME D i yo rJ M u#,P --6613 <br /> HOME or MAILING ADDRESS r" o FAX# <br /> (� v , Dox 2(30 (2�l) 334-0-7 2-1 <br /> cliY STATE Coq, ZIP R SZ41 <br /> L00 <br /> ',..BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> y' 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,STATE and F L laws. <br /> 'APPLICANI'SSIGNATURE: DATE: ��`�� a� <br /> :PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT D <br /> If APPLICANT is not the BILLING PARTY proof of authorization 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 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: X74 I L s r I�/3l LENT <br /> COMMENTS: <br /> SEP <br /> k J°AQUIM�U � <br /> ►� O14f <br /> 64LTH LOA e <br /> rrE <br /> AccEPTED BY: <br /> EMPLOYEE#: DATE: <br /> a �jLrc�re-r4 �3z1 ` �Co <br /> ASSIGNED TO: EMPLOYEE#: 73-79 DATE: 4160 6 <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: —?(,0/ <br /> Fee Amount: O Amount Paid k ,o� Payment Date Ot <br /> Payment Type t_� Invoice# Check# l Received By: Cs <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />