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SAN JOAQUIN -OUNTY ENVIRONMENTALREALTY "EPARTMENT <br /> IN- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE��R��V;;I��C--,E REQUEST# <br /> DpEN ACR/CG!<Tulz,4L - To B�REs/DENT G l 5 <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> R . F ^IX &A ✓14 2 0 <br /> FACILITY NAME <br /> SITE ADDRESS S D Ce TN STEi n/E4 4( LSCA Z-6W <br /> 02 .S7 Street Number Direction Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) aaa 0,1,7 fEX7-v^/ <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> LSCA Go Al C,4 <br /> PHONE#1 ' ExT. �19 <br /> PN# LAND USE APPLICATION# <br /> c 1 S73 -3 / 7B , 7-0,70-1t94 <br /> [PHONE 1#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^/ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEG PHONE# <br /> GO NI u c r/A/( o <br /> HOME or MAILING ADDRESS FAX# <br /> Lox 3 Z74 ( ) �6 8-Zs <br /> CITY 2 STATE cl'A <br /> ZIP <br /> BILLING ACKNONVLEDGEMENT: 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 appli. tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FED WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 00 ER AUTHORIZED AGENT <br /> i <br /> If APPLICANT is not the B/LLING 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 REQ ESTED: SKRF�CE kr35u�rr —,-O1/7-,41"1N,47-I on/ R��'O¢T >CXr FD�T�D VI 1-tJ <br /> COMMENTS: PAYMENT <br /> L,,�IVED <br /> US" <br /> �v AIIG 2 <br /> 4 2005 R <br /> SAN.IOAI)UIN COUNTY <br /> ACCEPTED BY: 1�� ENVIROMpAt LOYEE#: �- DATE: _ <br /> ►sem`A HEALTH DEPARTliv <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: aj <br /> Fee Amount: �5-7Z Amount Paid 4 3�/�-! Payment Date rl';�-Y(o <br /> Payment Type Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />