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JAN JOAQU1N UOUNIY'Lt,INVIRl1NIYIk;N'1'ALIIEALI'H 0EPART1VIEN1 \ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# "s SEERVICE <br /> QUPO; / <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SRE ADDRESS Z Sle �O D N V GLC T6 v1 C <br /> Street Number Olrection Street Name Ci ZIP Code <br /> r <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T APN# LAND sE APPLICATION# <br /> ( ' 6Z —O2o— a - j e? <br /> PHONE#2 EaT J]13OS DISTRICT.- - LOCATION CODE'" <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �GIY y)[XJ'1 CHECK If BILLING ADDRE55O <br /> BUSINESS NAME G.. ly� 1 yl PC C 1 V� PHO # <br /> S <br /> HOME Or MAILING ADDRESS FAX# <br /> ra h � d ( 1 931 2Z) <br /> CITY '-) cc <br /> 1/_\ c;V,� STATE (— ^ ZIP 9 5 215 <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �05t( 2 kgdll G'A.ul DATE: Auq 15 , 7062 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER /rOTHER AUTHORIZED AGENT <br /> 1fAPPL/CANT is not the BiLL/NC PARTY proof of authorization to sign is required/ Titte <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 at the same time it is <br /> provided to me or my representative. Q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> - ����QQ/J j,-�� . �vrw ..#"� �•� P v�S PSG X3\0 <br /> C,�VNGcu""1FwW"'✓ ,Tlect.'l• c en�y pN y��`�,��'�F"P� .... <br /> ,/R.¢v¢j CC�• � '' nets..,dc 5y,G�.B. _ SQpe���EN <br /> 0 <br /> APPROVED BY: EMPLOYEE#: /��7 DATE: <br /> ASSIGNED TO: EMPLOYEE#: yD / DATE: <br /> SFeeDate Service Completed (if already completed): SERVICECODE: 3 /S- <br /> Fee <br /> Amount: 17?vo Amount Paid Payment Date <br /> Payment Type . Invoice.# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUESTeFORM <br /> REVISED 6-5-G2 <br /> 0 <br />