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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/.OPERATOR _ <br /> t G`(Anoa G,Me C J C�G AN <br /> „Ve C, CHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEak <br /> SITEADDRESS O33 N S�c�teRove 9�i Fro►n�o�c�e Rd SA-DCA-Ann 015212. <br /> Street Number Direction St ee am !-� Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �1 k 2 1,0 S U 1 t j o S C-1l <br /> Stree Street Name <br /> CITYSTATES1vc- -ton C ZIP q lb 2i 10 <br /> PHONE#') EXT. APN# LAND USE APPLICATION# <br /> CO3 00, 1 <br /> PHONE#Z EXT BOS DISTRICT LOCATION CODE <br /> ( ) f! <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \�. <br /> �Q,II C.1 1(\ V S �j SU G CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> zoc 2ct$-tiv 2 o <br /> OME or MAILING ADDRESS FAX# <br /> blk'z Los ak OO s C,t <br /> CITYStoc ton STAR ZIP C4S2 D <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 Wthheork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards,S ATE d FEs. h moi{ rAPPLICANT'S SIGNATURE: DATE:03/os `9PROPERTY/BUSINESS OWNER OPERATOR/MA OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 REQUESTED: y I l SC r; st t' fA fE <br /> COMMENTS: N e o ! F g �►, <br /> J AQR 09 O <br /> �-10Ro�INco 0 <br /> �cTyo pyFNry ry <br /> ACCEPTED BY:� / EMPLOYEE#: DATE: z0`O N <br /> ASSIGNED TO: JEMPLOYEE#: DATE: yp 4.0� S 1Y✓1 <br /> Date Service Completed (if already completed): SERVICE CODE: 513 P I E: l6(j <br /> Fee Amount: Q ' Amount Pai �g D� Payment Date <br /> l,2Zb <br /> Payment Type Invoice# Check# Z Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />