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SAN JOAQUII_ 'OUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID I SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �e^ r r )I-WW.l AN ! H,Y4.e CHECK if BILLING ADDRESS <br /> FACLo NAME 3 3K Q ��"" <br /> -33'73 3 v Ac-a r k" <br /> SHEADDRESS 5 GH-lSMAnI A-04-0 T44 95371e <br /> �- Street Number Direction Street Name C' Zi CoCe <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY - STATE ZIP <br /> PHONE#1 E"T. APN# LAND USE APPLICATION# <br /> (It,rT �I —3tsc� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (f j� le'D GIJ CHECK if BILLING ADDRESS <br /> BUSINESS NAME r l PHONE# E"T' <br /> �ni6/rv�E(2/n1G I Tn/ L U - ?o? <br /> HOME or MAILING ADDRESS FAX# <br /> YD`fs CoRd vADo flvc ( 201) 95/2 - 0L/� <br /> CITY K-1z)/ STATE C A <br /> ZIP 95'Z d A <br /> BILLING ACKNONVLEDGEMENT: 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 /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ilk DATE: SI Z7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I fAPPL(CANT is not the B/LUNG PAk1Y 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: <br /> Cow%Nrs: ; It-41r A.I°i� v-�t " L It r A J"' RECENED <br /> �-�7�10'I 11¢eG�t- du`I''"•�` v"�' 1 � Mum �. <br /> /� z/o�/ ,� u` i,�4rJ•.'-i> ryf 6D u%y °�� g 31�a•,� Y , MAY 2 7 2004 <br /> ��leVl°`( c✓C e� ts` +%ItCf� CTD / 'cgl� �O.n•� SA ENOAQUIN LNV <br /> a NM nPIRR�MErtr <br /> ACCEPTED BY: o(--t v� I EMPLOYEE#: r)J�Z / DA : S' '�,� 0 <br /> ASSIGNED TO: ESS EMPLOYEE#: 5 DATE: 2-7D <br /> Date Service Completed (if already completed): SERVICE CODE: 131 s PIE: <br /> Fee Amount Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />