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SANJOAQUIN COUNTYENVIRONMENTAL HEALM DEPAR'T'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> F2nAFST Gu,DEL CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS 2661B LpW�/L S`AG�IM(„M ,P�..4p S (C jt!^U 9503 <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#1 ExT. APN# LAND USE APPLICATION# <br /> �aA) 33y- GCiS oGs� o3o _ os <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR p ���---,,,,,,��1 <br /> It/1,1 � /���rrrv—I CHECK If BILLING ADDRESS <br /> 11 <br /> BUSINESS NAME 0Ir L. ' 1� AJwe y -6C/3 <br /> PHONE# EXT. <br /> HOME or MAILING ADDRESS f FAX# <br /> Q, o. 6-,< Z( Po (z•ti ) 33y-07Z3 <br /> CITY LA 17 1 STATE C4 ZIP Q3 2 <br /> rI <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' S ( Z "a 6 <br /> DATE' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ACER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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: rA. 5 <br /> COMMENTS: � 1 ls��d p,E <br /> 't Z�I dl0 ' �Az2 0 ENTH oEP <br /> ACCEPTED BY: EMPLOYEE#: DATE: O <br /> ASSIGNEDTO: 224 MPLOYEE#: r7 / DATE: <br /> Date Service Completed (if already completed): SERYICECODE: Y PIE: Q <br /> Fee Amount: / Amount Paid Payment Date 5 <br /> Payment Type ✓ Invoice# Check Receive By:kc <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />