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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> c rWEMT Gam- SROO4b89S <br /> OWNER 1 OPERATOR <br /> W L 2 Ve_0 v CHECK if BILLING ADDRESS <br /> FACILITY NAME G <br /> -CoA/ '5aa1P1*?E,*4T 4Cc1Mt0AA1 <br /> SITE ADDRESSM"SPAZ_e6 L4TyaoP ?I 3307 <br /> 00 000 Street Number Direction S Name C' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> .40 Street Number Street Name <br /> CITY STATE ZIP <br /> a <br /> PHONE#1 Err. APN# LAND USE APPLIC nON# 111 <br /> PHONE#2 EM BOS DISTRICT LOCAnONCODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> EsNF CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> "67_/40 <br /> aG 8- o <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/oI 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 ap 'cation and that the work to be performed will be done in accordance with all SAN JoAQuIN <br /> COUNTY Ordinance Codes,Standards, TE and laws. <br /> APPLICANT'S SIGNATURE: DATE: 7—O� <br /> PROPERTY/BUSINESS OWNER OPERAT R/MANAGER Ken <br /> OTHER AUTHORIZED AGENTM <br /> I,f.4PPLICANT is not the BILLING PARTY proof orization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: pplicable,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 JOAQUW COt7NTY 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: AlT A 8 APA Al SY f 1 r0l" <br /> COMMENTS: .% PAY E(--IEp rr <br /> Ecc L �C,O r?�EdJ ,�- -(/� -Cf <br /> -� " � l <br /> >i r, SAN J IN Coot v <br /> EN-TA <br /> ACCEPTED BY: F`✓ . U r f ✓J A H�LTH DE'P [;��E <br /> LOYEE#: G3 u DATE: <br /> ASSIGNED TO: �� Jfl; EM 53Nb DATE: I •� QS <br /> Date Service Completed (if already completed): SERVICECODE: S 92S PI : �(o.FJL <br /> Fee Amount: x:00 Y 1 439 1 Amount Paid -4 R30• D-D Payment Date ( 1 DS <br /> Payment Type L,,-� Invoice# Check# Received By: <� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> \ REVISED 11/17/2003 <br />