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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ZOWNER�SiDN7~IA G �i4� �cclCru2a L S24d 4 4z 9)2- <br /> OWNER/ <br /> R// OPERATOR ,}/�o /� ,,/S/ ! S• Cf'r/4 1-,F5AND q rm CHECK if BILLING ADDRESS <br /> Z <br /> it <br /> FACILITY NAME <br /> SITE ADDRESS Ie JAAIANT ROAD A e;4✓YJPO q-,—xjLo <br /> /0/ / <br /> � Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ExT' APN# LAND USE APPLICATION# <br /> ( ) 3 - 1 -320- PA - os --5-74 <br /> PHONE#2 ExT. [BOS DISTRICT JLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dow I CHECK if BILLING ADDRESS <br /> BUSINET <br /> ESS NAME „/ !/!"� ,y PHONE# ExT. <br /> GASIV!� <br /> HOME Or MAILING ADDRESS FAX# <br /> P 0 • $aX 3-774 <br /> CITY LO L STATE CA ZIP R530 <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, S and FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: /O • <br /> PROPERTY I BusiNESS OWNER❑ OPERATOR/I1'I4N4GER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BiLLiyG 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: Y&/i_ Sa ,TAB/L/ u � D I TI; �✓/� <br /> COMMENTS: RECEIVED <br /> 10 2605 <br /> �lumvT <br /> SANNVOAQUI IRONMENYAL <br /> ACCEPTED BY: Lt UI ,Q A EMPLOYEE#: ®3� DA . /Q /0/0'f— <br /> ASSIGNED <br /> 0a'f—ASSIGNED TO: (L� EMPLOYEE#: Del`( DATE: f C) r'p <br /> Date Service Completed (if already completed): SERVICE CODE: s.2Z �Zy P!E: <br /> Fee Amount: `e&-ry �2- #' •E Amount Paid -�?J--jam 0 0 Payment Date tO O flS^ <br /> Payment Type ✓ Invoice# Check# 0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />