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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#Q <br /> DA/R 90r4 AD O <br /> OWNER/O ERATOR <br /> fJ IL /r/1L -IZV5/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> F,4RIA <br /> $Ra enngcss 'A 4SL E ' 1 A— 1 A "a�51 /UJ d"TLC� rd72 9S3zo <br /> .� Street umber uirec __ city <br /> A ZIPCode <br /> /1 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 02 .,J32 sEl Dlt/E/Z ✓E. <br /> Street Number Street <br /> CITY STATE ZIP <br /> E5eA 40AI IIA <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (W?) <br /> 0205- /So-!3 <br /> 05 - --A CIS-- o l�-13- 2-y-(n <br /> PHONE#P Ez. BOS DISTRICTLOCATION CODE <br /> (tog) o47- z3 i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> j10 ./ CHEsn1E CHECK If BILLING ADDRESS <br /> BUSINESS NAME /VV PHONE# ' <br /> )20 o5T- PRrrGHArZD CON-(acr/AlC 00-?-2 300 <br /> HOME qr MAILING ADDRESS FAx# <br /> '�T!- 0 15 o a St,t t-rE lea (201 ) 809- 2z90 <br /> CITY /19 p p6lTo STATE e9A ZIP cls 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 TE and FE laws. <br /> APPLICANT'S SIGNATURE: DATES: .3 <br /> / 3/- / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑authoB OTHER AUTHORIZED AGENT <br /> IJAPPLICANT is not the BatmtG PARTY proof of rization to sign is required Time <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: 374RFAG,e iNA Tian/ REr'oizT-A FVEmr✓ <br /> COMMENTS: <br /> 7 /gay RECEIVED <br /> /A9.F-65� JAN 31 209 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: MPLOYEE#: <br /> ASSIGNED TO: ,1 EMPLOYEE M DATE: <br /> Date Service Completed (if already com leted): SERVICE CODE: <br /> Fee Amount: D Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48412-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />