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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A c L- 'ap-&a&10S-f <br /> OWNER/OPERATOR <br /> lc-eL �/���/L Tit Gl',7— <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> GAAZ/A A—AR.w/ r <br /> SITE ADDRESS f,15-3/ 20 <br /> Street Zi1tip�!•11�oril� Yt Z Ci Zi Code <br /> HOME or VAILING ADDRESS (If Different from Site Address) 0203 Z �!E/DN i2 /�✓E�Gr'F <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> SeA Z-0A1 Ci4 9530 <br /> PHONE 01 EXT APN# / LAND USE APPLICATION# - __ <br /> �9 ) d S- 79,,l .205 13 F - 3 0490 2-4 <br /> PHONE#2 EXT. BIOS DISTRICT , LOCATT1 N CODE <br /> ( ) <br /> 444— 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I' <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE 11 EXT. <br /> PA r7Va: -r C 120 D SGIGT A/ ZO -/6s2 <br /> HOME or MAILING ADDRESS FAX# <br /> 47401 o /TF O ( ) <br /> CITY /77 Ap JE5T-0 STATE CPA ZIP S� <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,S and FE laws. <br /> APPLICANT'S SIGNATURE: DAT. /E,..:� <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT 19�J <br /> If APPLICANT is not the BILLING PARTY.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 same time it is <br /> provided to me or my representative. �Q <br /> TYPE OF SERVICE REQUESTED: 50/L f K/Tq Td/L/ fTG(!> i2EV/>c V✓ F /� <br /> (` tl � SNo 2 <br /> CaaeNTs: 1 e11�' dl aS lZ �,L Ctv� � 1 yly��ogU/Nc?�14 <br /> wt.c...V ovu> TyOFp ENTDUH <br /> QATMFN <br /> T <br /> ACCEPTED BY: G EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Competed (if air dy completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pai o2S- � Payment Date <br /> Payment Type Invoice# Check# '7�1i1 Received By: v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />