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SAN JOAQUIP' "OUNTY ENVIRONtAEN%kL HEALTV T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN IOPERATOR <br /> I� S`tom CHECK If BILLING ADDRESS <br /> FACILITY NAME A , �1 T <br /> S¢EADDRES( S /✓(DREG-y �/ `'r �rhf lv✓1 C/ SZ3U <br /> ((op Street Number Direction Street Name C' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 / t L�d�/ ) Street Number Street Name <br /> CITY ��/✓{. STAj�E ZR J Z 3e.)PNONE#t Ea . APN# LAND USE APPLICATION#''( <br /> ( ) v 9 - Z 40 lbs- /v - o l a z Pi+ 0 3 4� <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLINGADDRES <br /> BUSINESS NAME 334— 3E><r <br /> t PHONE# / <br /> r,/t LLG�IN 7 J� <br /> HOME VAILING ADDRESS FAX# )// —Q'7�-S <br /> �" ( ) J 3YY <br /> CITY U�)1 / STATE ZIP <5y2'.<f <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 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,Sta ds, STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: �� DATE: <br /> PROPERTY/BUSINESS OWNER RATOR/MANAGEiR�❑ OTHER AUTHORIZED AGENTlfAvRucAAt is t�O)P <br /> LLNGPAR77 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 ap4t the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: So/L - 'Lc t7-6-61 L / d R�c <br /> Cq/oS: <br /> I ��/ y PQR GOUN� <br /> 6 k /o f 6 /otP N JOPO NMENCP�NT <br /> /�ydL7/1Q/16r:�-'7 SP4etvaR PPRtM <br /> Gyl,�tx�v N <br /> ACCEPTED BY: L. I lJ G 42--� MPLOYEE M O 3 z-/ DATE: r.l. CJ4 <br /> ASSIGNEDTO: �� l-� EMPLOYEEM - DATE: 4 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: O� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />