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SAN JOAQUIN`rOUNTY ENVIRONMENTAL HEALTH D.01 <br /> EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> iQES/19 r/ L SERVICE REQUEST# <br /> OMEN <br /> OWNER/OPERATOR 452004 /4 (, o <br /> FACIDTY NAME 4J� ,Q <br /> " "a��` " t CHECK If BILLING ADDRESS <br /> SITE ADDRESS JQ 7+0 <br /> Street Num ber m �20AJ17;gyE JTd � 9sz r z <br /> Direction Street Name <br /> HOME Of MAILING ADDRESS (If Different from Site Address) /d •/G cityii cove <br /> �S 5 TON ^^Dr rStreet Number <br /> CITY Street Name <br /> 5 OG ON STATE ^, ZIP <br /> 95 <br /> PHONE#i Ez', APN# CA zip <br /> ( ) — 49 <br /> LAND USE APPLICA ON# <br /> Al <br /> PHONE#2 EXT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR � <br /> C r/�V CHECK If BILLING ADDRESS <br /> BUSINESS NAME Alfu r/- // PHONE# ExT. <br /> HOME Or MAILING ADDRESS /V L FAA# O <br /> �3©K ( ) l06 -ZS o <br /> CITY /—6? <br /> zip <br /> /�!j STATE <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this aappliion aADWS. <br /> work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S[andordsF <br /> APPLICANT'S SIGNATURE: DATE; 7- p5PROPERTY/BUSINESS OWNER❑ OPERATOR/ Of ERAUTHORIZEDAGENT� <br /> /JAPPL/CANT is not the BILLING PARTY pro of author ation[o 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: N E <br /> COMMENTS: OJ/ _ <br /> j��A�27Re/t�ly> yl�3fa�s RECEIVE <br /> MAR 7 200 <br /> SAN JOAQUIN COUN Y <br /> IRONMENTAL <br /> ACCEPTED BY: rC)Li I EMPLOYEE#: C 3 2( DATE: HFJ\ I( jlaP FITME <br /> ASSIGNED TO: CSC. OTTv EMPLOYEE#: Sr7y DATE: .._3 -716-5 <br /> Date Service Completed (H already completed): SERVICECooE: 3 /,S P/E: O j <br /> Fee Amount: �(o ,U� Amount Paid LrC) Payment Date Z O� <br /> Payment Type ✓ Invoice# Check# ,.Z ' Received By: <br /> EHD 4"2-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />