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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prcperty FACILITY ID# SERVICE REQUEST# <br /> GA cLk t-/V�D o&74- <br /> OWNER/ <br /> 4- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Bol i/A t.E <br /> SITE ADDRESS i LATVV E> MIEN EC-, <br /> 1/37 „rreet Number D coon Stmet Name Ci- <br /> HOME <br /> i HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number L Street Narrie <br /> CITY STATE zip <br /> PHONE#1 CYT' APN _ - LAND USE APPLICATION <br /> (2 0-51) 92-y 2-7GQ) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> LC SP-JkGF--S <br /> HOME or MAILING ADDRESS rt FAx# <br /> V T s l __T__ �______. osc?) -I — <br /> CITYSTATE / n zIP - 7-7 u <br /> ,Pr_ SN�: CA J <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 ENVIRQNrdENTAL 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards FED laws. / <br /> APPLICANT'S SIGNAT �� E: .__ DATE--::- �,/ 2'�/3 <br /> PROPERTY/BUSINESS OWNER lJ OPERATOR MANAGER Q OTHER AUTHORIZED AGENT L. <br /> tIAPPLICANT IS not tt1E t31!_LIA/G TY, pCQt of authorization 20 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA ON: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data avid/or environITIental/site assessment infom7ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time it is pr1o,d4ed to me or <br /> my representative. FF'' yI <br /> TYPE OF SERVICE REQUESTED: 61 /`'t <br /> COMMENTS: -1;7zEPLACc� >teSf�C. �0'J�JL� U�CV-V-n'� Sl2/VSt�� C/S7> 2 4 201 <br /> SAN JOAQUIN CO <br /> HEAD-H p A4E PAR-MCITY <br /> ACCEPTED BY: `:1i1 n I rl EMPLOYEE#: Z6 7 O DATE: <br /> ASSIGNED TO: f/ lP /V EMPLOYEE#: D r DATE: Y <br /> Date Service Completed (if already complete /., SERVICE CODE: P 1 E: .Z <br /> Fee Amount: 7 S Amount Paid - S,p� Payment/Date <br /> Payment Type Invoice# Check# 1oZ77 Received By: <br /> EFID 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 QW-11 <br />