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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> Fsi FNT/A Sl2u D q5-aCU <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Ag-rago jr REAlAnoFa <br /> FACIL"NAME <br /> SITE ADDRESS 1-1E10 7-7— Z/NDE,/ f5-2 -746 <br /> Street Number Direction Street Name City Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) g06- S9 (o O oTo - 3 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> )\O CNECK If BILLING ADDRESS <br /> BUSINESS NAME 'V PHONE# EXT. <br /> C{/�S� 9E Nlu6 1 wl6g-1¢03 <br /> HOME or MAILING ADDRESS Fax# <br /> 0 . 50K ( > n1 0-2Sf'B <br /> CITY ry STATE /r ZIP S— <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 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 appli ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 7- <br /> PROPERTY/BUSINESS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of a horization to sign is required Tate <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: SQ/L SU /7—,q13/L/T kv EN M EV(SfoN p'qy <br /> COMMENTS: I Z'/7-,;,/o C60'"'�""� %A4.e-d /V/o / D�.L 2 FIVF� <br /> .9� f\ 1 �� .r) �° ^�^ 2 2005 <br /> SqN�Oq <br /> H NVIR�UMECOU 1Y <br /> liD <br /> PAL <br /> ACCEPTED <br /> ACCEPTED B EMPLOYEE#: DATE;. ` <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> / to \ <br /> Date Service Completed (if already completed): SERVICECODE: SZ Z PIE: - J <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />