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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G - -5-—to lz.L IF °1 / b 9.ab S 113 <br /> OWNER/OPERATOR <br /> /?&7F/A[1" <br /> ?l /A[1" /'Eyc 7 A 2 L LLC CHECK If BILLING ADDRESS� <br /> FACILITY NAME r� Gam} il 8.y?Ct (� <br /> SITE ADDRESS 35- <br /> Alrajf Gl 1�e--1 C- D A-Cl <br /> Street Number Direction Street Name city ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) *6�,�It <br /> qQoo fly 7S <br /> r <br /> J /i!CC Street Number Street Name <br /> CITY r O STATE �J ZIP C� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (,1 ) 250 J '0o p q-5 J <br /> PHONE#2 EXT. BOS DISTRICT LOCATIOpLCODE <br /> � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ZW LL f Fl, /nV/ EG_h— <br /> 'G U—it CHECK if BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT <br /> . <br /> 6Pe9P1.4'A 67:5 <br /> .-v 626 -,113 2 <br /> HOME or MAILING ADDRESSFAX# <br /> �77AI 'X/-o TS ( , <br /> CITYA A ! i1 _ lTomt STATE -� i ZIP 78 ZSS <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 application and t5at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F &RAy laws. <br /> APPLICANT'S SIGNATURE: �` -� DATE: ■� <br /> PROPERTY/BUSINESS OWNER❑ 1:1OPERATOR/MANAGER OTHER AUTHORIZED AGENT AY��IEN�" <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required TitleKECEIV�D <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property ated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si iERsAs3ie2V19 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ati �aMe time it is <br /> provided to me or my representative. ENJJVUIAQUIN COUN7y <br /> L <br /> TYPE OF SERVICE REQUESTED: TH DEPAR NT <br /> COMMENTS: <br /> OF <br /> p&A <br /> ACCEPTED BY: EMPLOYEE#: DATE: i l <br /> ASSIGNED TO: EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: / Q <br /> Fee Amount: Z Amount Paid S Payment Date Z <br /> Payment TypeInvoice# Check# 2, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />