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oSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENC O <br /> SERVICE REQUEST <br /> PED <br /> Type of Business or Property FACILITY ID# S VICE REQUEST# alµ„( <br /> 5 k©6 s kv <br /> OWNER/OPERATOR _• „ C l I - CHECK N BILLING ADDRESS[] <br /> FAcanYNAME ' 6 <br /> SITE� <br /> yS lIDYG 2 Stetmr O�tlan ^ ^ <br /> 1 r I n/ S Stmt Nam <br /> HOME or MAILING ADDRESS (N Different fromSNq C <br /> Ad/�dmss) <br /> iO S "Q •`•/� <br /> `l N bar Stoat Name <br /> CITY 5 r�J STATE 4 zip N n <br /> r7 I S <br /> PHONE#I APN# LAND USE PLICATION* <br /> / !/ <br /> ( ) 17 -0 (.4 r-041- 7 46 6�1* RJ <br /> PHm#2 �' BOS DISTRICT LOCATH) E <br /> ( I 2- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR —E)O` '� Q <br /> V w \ CHECK HBILLING ADDRESS <br /> BUSINESS NAME ER <br /> RIE-N/U7r -r\r`�s�l'�Q'av / PHONE# <br /> HOME MAIUNGADDRESS uC O FAX# J <br /> `�._� 15 ] ( <br /> CITY W C.1 l STATECA LP 9' (•� ' <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 1 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. _ J1. <br /> APPLICANT'S SIGNATURE t-�6.t,I,(\r �j p,ei -�rlrucdP - DATE: (2� <br /> T <br /> PROPERTY/BUSINESS OWN ER❑ OPE TO MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PAR TT proof of authorization to sign is required Tule <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 t0 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: IS T <br /> COMMENTS: S/ZL J0. RECH L <br /> JZt�cQ7) Jil j ^°u'°k' DEC 13 2004 <br /> t/•�.E �77o '. P' �� <br /> ../pA.rC0 <br /> I SAN NVVIIRONICOUNTY <br /> ENVIRONMENTAL <br /> MFNT <br /> ACCEPTED BYE EMPLOYEE#: DATE: / 3 G <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid $ Payment Date <br /> Payment Type Invoice# Check# '717 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />