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i <br /> �,T� _ :; f. 3:s�A IJO ► fJXl�lINW1,;jLWV,1R0NMENQI�f�L?1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9FS/DENT/,4 L ,Q 4 R 1 C L.Tk2x e-- <br /> OWNER <br /> OWNER I OPERATOR <br /> /'72 S, .T�ts r D gFAa4I�Lt I CHECK if BILLING ADDRESS❑ <br /> FACam NAME <br /> SITEADDRESS S #4 /a g9AmK S 7i2�Cy 71 9r,? -7 <br /> ,7-7475' Street Number Direction Street Nae C Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)1/2 31 <br /> a-StreeNumberStreetNarmt y <br /> CITY L STATE /+ ZIP <br /> ZA 14 Ef (� e <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c ' - /'IS .- a /- ate <br /> PHONE#Z ExT• BOS DISTRICT LOCAnoN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REaUESTaR "/� <br /> )0A/ C/lE fA115 CHECK if BILLING ADDRESS <br /> BUSINEss NAME +� PHONE# Ext. <br /> G E SNE CoIV U L A/ S- CJ <br /> HOME or MAILING ADDRESS FAX# <br /> CITYr— L O STATe GA ZIP <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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUM-Y Ordinance Codes,Standards,S and F laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PitOPEP,TY I BUSINESS OWNER❑ OPERATOR//MANAGER ❑ OTHER AL"o mzED Ac-ENT <br /> IfAPPLIC,tivT is not the BILLING P�RI�proof of llrorizaiiori to sign is required rtr fc <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 JoAQUfN 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: N!rR ArE G 04 b/r✓ Sall- .fu t r A,3/e-Iry 57-1<D11---S & ✓!F�(,./ <br /> COMMENTS:tr/S'� �/?•� PAYMit.�.� RECEIVED <br /> OCT , g 2004 <br /> SANjQAQtlrry cOL1rV <br /> rvvr TY <br /> ACCEPTED BY: J' EEmPPL0YE1E#' <br /> LOYEEM 0 �-/� -DEPARTMENT <br /> ASSIGNED TO: ,�� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: <br /> Fee Amount: 11P b S 0 Amount Paid 1i Lt&5-,O 0 Payment Date /() D <br /> Payment Type ✓ invoice# Check# 9)rs-- Received By <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11117!2003 <br />