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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EeuJ '2* - 0b-7yq <br /> OWNER/OPERATOR L OCHECK If BILLING ADDRESS <br /> G� Q'ls'E 'f GW6 <br /> FACILITY NAME <br /> SITE ADDRESS(: <br /> DDRESS2 1V£R— GZ-e/L7 ESchW..t �s32o <br /> tree(Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 27&15E:. DoD Ot R*AD <br /> Street Number Street Name <br /> CITY �S. J STATE (2-atL ZIP C?r <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (ZOR ) 765- 5966 S_zbo- 09, Jiflz %/ Pp -15�2� <br /> PHONE#2 Enr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I l4- �y CHECK If BILLING ADDRESS <br /> BUSINESS NAME r��' 1' PHONE# EXT. <br /> M�tiV Za 3 7�}-6 613 <br /> HOME Or MAILING ADDRESS FAx# <br /> e- 0 . 1?ax 7-190 ( Zoq ) 3 -o-77- - <br /> CITY LOD i STATE G,4. ZIP of C-Z4-1 <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 we or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be perform will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> y S z*7—�� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT iJ �f ✓%� e <br /> IfAPPL/CANT is not the BILLING PAR TP 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s143(Ime it is <br /> provided to me or my representative. Y <br /> TYPE OF SERVICE REQUESTED: LA 4A <br /> COMMENTS: SAE JUA /'/V <br /> 7 /G , w1"'� HFa<�iYgoMN�v <br /> ko > 60 5-13 SFA RT�FN <br /> . M � <br /> ACCEPTED BY: EMPLOYEE#: DATE: S•� l <br /> ASSIGNED TO: _xT'La EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: -�3 PIE: <br /> 2 1 <br /> Fee Amount: 2 Payment Date <br /> Payment Type Invoice# Check# 3 G { Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />