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* t <br /> a SAl" JOhQUIT OUNTY ENVIRONMENTAL HEALT PARTMENT - <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESSt—p �. a <br /> Street Number Direetion Street Name Cib r"41 Code <br /> HOME or MAILING ADDRESS (if Different from Site Ad/dress) <br /> S Street Number Street Name <br /> CITY AI STATE i zIP eFY6 3 Z <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# O j <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> { J <br /> CONTRACTOR[SERVICE REQUESTOR <br /> REQUESTOR �> <br /> -fit-, CHECK if BILLING ADDRESS <br /> .��,�,, <br /> BUSINESS NAME PHONE# Exr' <br /> GL AoZ elg [-1'-3 7S' <br /> HOME or MAILING ADDRESS ` FN(# <br /> `3�- �it rl �aVlCiG� fes[ a {o`k J �l 3 f-- 2 -3 -73 <br /> CITY /'f0 G� STATECt.* ZIP <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 ENVTRONmENTAL 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 JOAQUN <br /> CDuNTY Ordinance Codes,Standards, and F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: D /r 0S Y <br /> PROPERTY/BusiNEss OWNEROPERATOR/MANAGER ❑ OmERAUTHoRl DAGENTII Cl,//L <br /> IfAPPLicAvT is not the BI1.LWGPRR7Y.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 environniental/site assessment <br /> information to the SAN doAQUTN CouNTY ENvSRQNmENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. rr " <br /> TYPE OF SERVICE REQUESTED: ��'1/lic> oS p/f �G16 L'�i It �TVGy <br /> COMMENTS: <br /> QW, <br /> lt'E ' NOV 9 <br /> SAN ]QAQ0N COUNTY <br /> D <br /> X04 Y 7 zoos � �5' W pGENv4RONMEN <br /> -SA/V,10.4 <br /> EN O�QUIN -a �,=pA� � <br /> V C <br /> ACCEPTED D� NT EMPLOYEE#: DATE: If G <br /> ASSIGNED TO: A--�C EMPLOYEE#: s��� DATE: <br /> Date Service Completed (if already complete. SERVICE CODE: 5'22 / PIE: , <br /> Fee Amount: ��-(o,� Y unt Paid i 06 Payment Dat ` i 6S <br /> Payment Type t/ in nice# Check# 3 3 Received By: iV <br /> 010 D217l20O3 1�b� D�� \`�'� R ORM(Golden Rod) <br /> KE151=D <br />