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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> S VICE REQUEST# <br /> 5 k�6 5C <br /> OWNER/OPERATOR n / <br /> CHECK M BILLING ADDRESS O <br /> FiciurY NAME <br /> SITE ADDRESS i <br /> It G Lt L l Number DltNoo shim TVI A l ti ST Nam. <br /> HOME or MAILING ADDRESS (If Different from Sky Address) <br /> t t� S V A_Q '/��^/ <br /> N bar Street Nam /] <br /> CITY STATE 1] ZIP I-7 921:5 <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# / <br /> 1 1 17 0-0 q Yv-Oq- )-4 <br /> PHONE 92 E T. BOS DISTRICTLOCATI ODE <br /> ( I11 Li <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR y� <br /> —f::�O v Q Q • CHECK N BILLING ADDRESSL I <br /> BUSINESS NAME 96-NA) 77— IJEWXOPW&�� l PHONE# <br /> HOME p�MAILING ADDRESS F _AX# )7 3 Q� <br /> Y- I5 7 <br /> CITY \—o <br /> NG,.`� ( STATECA ZIP L7�L(•r I <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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r-r t_t,(\r �/,Q.ti -'�¢nI1e't" , DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERAT MANAGER ❑ OTHER AUTHORIZED AGENT[3 <br /> JfAPPL/CANT is Hot the BILLING PARTY proof of authorization to sign is required Titre <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 enviromnental/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: S T <br /> COMMENTS: S/zG jGLr' r�7 ;Omr RECEIVLU <br /> (Zr 'ce7Jitz` j !vert"' p E 0 13 2004 <br /> • ,^Its1 SAN JOAQUINCOUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BvY'—� EMPLOYEE#: DATE: / G <br /> ASSIGNED TO: �. EMPLOYEE#: DATE: - <br /> DateServiceCompleted (N already completed): SERVICECoDE: I PIE: 2(Pd <br /> Fee Amount: Amount Paid LPayment Date <br /> Payment Type Invoice# Check# :.� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />