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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> >✓ SERVICE REQUEST s <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S►2oc).4A3 of <br /> OWNER/OPERATOR A <br /> r,a.1; CHECK It BILLING ADDRE55O <br /> FACILITY NAME <br /> srr€ ell s J/fC/< I0-2e �ID. �ponJ <br /> I Street Number Dlrectbn Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (5Diffe/�from Site Address) <br /> "' �W&.2 VA,) <br /> Street Number Street Name <br /> CITY (Z120"J <br /> ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (269 ) 22 _ 07o- 1s PA - 04-46/ (AAS) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �t/1 //,, <br /> �"` )Gry 4t 1— CHECK If BILLING ADDRESS <br /> BUSINESS NAME l.i M1l 0 PN E# E'R <br /> � X99_ <br /> n1 HOME or MAILING ADDRESS FAX# <br /> n 5(tp 2 V'40 /CEn/ w ( ) <br /> CITY //, &,j STATE /] ZIP C?r--3 6 �` <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 p rfom ecrwill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: e" - mA c1rv.Y (' '0 " DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPL/cANT is not the B&LlNG 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 at the same time it is <br /> provided to me or my representative. n <br /> TYPE OF SERVICE REQUESTED: 90tL Aqt-cc7!5-6 rct .17-tt,tl . i-1¢.4 <br /> COMMENTS: //1/ 1� l I Z,/(S 'y r7 .er...� I V E D <br /> OCT 11 2005 <br /> 2 ?Z i _ 6 yY SAN JOAQUIN COUNTY <br /> ,a_ -- / �Q I ENVIRONMENTAL <br /> ACCEPTED BY: O EMPLOYEE#: 03)q DATE: 10 (1 <br /> ASSIGNED TO: 14Lt C) <br /> -�S EMPLOYEE#: f(( DATE: (D a Q� <br /> Date Service Completed C9(if�already completed): SERVICE CODE: S2Z `7`ZL P/E° <br /> Fee Amountfl�(o'CIU )(2J372,D Pid `S'A -2—G 0 Payment D to - <br /> Payment Type ✓ Invoice# Check# r Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />