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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> c u c Es/DEM / S&o(o 13$4 <br /> OWNER/OPP/ERATOR <br /> 117f2jr. S E E O S CHECK If BILLING ADDRESS <br /> R . e <br /> FACILITY NAME <br /> o2R/gSSE 2m <br /> SITE ADDRESS gB,�/ /� cTA 5To c KTo,J 9S2/S <br /> Street Number I Direction Street Name city Zia CoA <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> G^ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t APN# LAND USE APPLICATION# <br /> Uar) q3/ - 17.¢5"5" 6 .2 V 19 - oW P _ 000✓7a <br /> PHONE#I Em. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR --771� <br /> !/O� CL1ES�/E CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EM' <br /> Ar'�Z rOMS ) (oG <br /> HOME or MAILING ADDRESS FAX# <br /> . o . ( ) 6 0- 25"90 <br /> CITY Tu 9 L D GK STATE GA ZIP 5-30 <br /> / <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,ATE and FFl4RAL laws. <br /> APPLICANT'S SIGNATURE: O — DATE* <br /> PROPERTY/BUSINESS OWNER❑ / L <br /> OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT Y <br /> IfAPPLICANT is not the BILLING 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. <br /> TYPE OF SERVICE REQUESTED: SuRFAGE u65tt2FAcE - /n11VA 7-/OA/ E✓tEbt/ <br /> COMMENTS: REgyMEjV. <br /> nary JQa ?Ob <br /> -j�C:l7G✓ N ENN Q <br /> ,�,���, ��'l p HMfly1WA'1Y <br /> ACCEPTED BY: EMPLOYEE#:: DATE: , Cg ItC ENT <br /> ASSIGNED TO: M. � t�-� EMPLOYEE 5[1414 DATE: tt /OC�(to <br /> Date Service Completed (If already completed): SERVICE CODE: 3JS PIE: .03 <br /> Fee Amount: oo Amount Paida'4Payment Date ) d <br /> " Payment Type . Invoice# Check# 3 1 y Received By: N-rr- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />