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JSAN JOAQUIN COUNTY ENvu.tONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropeRy <br /> FACILTY I <br /> ID# SERVICE REQUEST # <br /> So k a CHECK It BIL <br /> `i� !2 A <br /> OWNER OPERATOR /C / / LING ADDRESS❑ <br /> FAatm NAME 5-oeL�� .C.-G.C_ <br /> WE ADDRESS 63a ' /'a ` S <br /> Sae Number i of A / �' rcet <br /> HOME or MAILING ADDRESS (If Different from Site Address) STATE <br /> Numaft t <br /> 9tna Number STATE <br /> CITY <br /> ExT. APN 11 LAND USE APPLICATION M <br /> PNONE#t <br /> ( ) <br /> BIDS DISTRICT LOCATION COVE <br /> P140ME 02 EXT. <br /> t ) <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> Al, L � GMECK If DILWNG ApORESS� <br /> REQUESTOR Gr-l- A /a/.-T ilo-S <br /> f � EaY. <br /> 8 <br /> P N _ O <br /> BUSINESS NAME 49 N& <br /> HOME Or MAILING ADDRESS//2_4 '6 it y <br /> (C STATE ZIP <br /> GIT/ Oj! v11111:11 1101- <br /> arr* <br /> LE GE NT: I, the undersigned property or business owner, operator or authorized <br /> G ACKNOW "1 1 agent o[ cmor <br /> nc�Owlthat ll site and/or protect 9peaeife ENVIRONMGNTAL,HEALTH DEPARTMENT hourly charges associated with this prof <br /> activity will be billed to me or my business as identified on this form. cc with all SAN JOAQUIN <br /> I also <br /> .(certify that <br /> have Codes Standards,STATC and a nthat t la".he rlc to be performed will be done in accordan <br /> DATE: <br /> AppLICANT'S SIGNATURE: OTHER ALRRGRI7.1<D AGENT❑ <br /> Lu�,�!OWNE OPF.KATOR/MANAGER ❑ Title <br /> PpppgpTY/BDaiN6SS PLICA f� Rn t m'G P.1RTr proof o authorization to sign is required <br /> /JAP✓'LIC.f Ls no! the_ r 0 .f j <br /> AU OILi7.ATION TO RELEASE INFOIzNtATION any applicable, I.the owner or eotechnical datapand/or environmentall ite cassessmant <br /> above sits address, hereby authorize the release of as and all results, 6 <br /> information to the SAN JOAQU11N COUNTY ENvtRONMGNTAL H1;A.LTH DEPARTMENT a5 Soon as it is available and at the same time it is <br /> provided to me or my representative. e <br /> TYPE OF SERVICE REQUESTED: <br /> %�l✓ a ,a t InQ 1 <br /> COMMENTS: <br /> ACOEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED to: EMPLOYEES DATE. <br /> Date Service Completed (if already completed): PIe 4 <br /> t <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type invoice# _ Cheek# _ Received By-, <br /> FHD 4$-02-025 post-it'Fax Note 7671 Date!"2. ' Q7 SR FORM(Golden Rod) <br /> REVISED 1 111712003 <br /> TO Prom / <br /> C.JD'P S G o E <br /> Phone# Phbno N <br /> Fax# — 3 /JJ( Fax# . <br /> -v <br />