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JAN JOAQL*OUNTY LNVIRONMENTAL HEALTHI,'ARTMENT <br /> SERVICE REQUEST <br /> Type of Bu4IMn)Vr6MkW FACILITY ID# SERVICE REQUEST# <br /> APR 12 2017 Z--7 77 Z <br /> OWNER I Q{��(;1�95 i / CHECK If BILLING ADDRESS <br /> M-5 <br /> Ger ( c�i LLL. <br /> FACILITY NAME ) rA 1 <br /> farad SC- <br /> SITEADDRESS $"09S SIG^ro Rd • SfOGrc+-tv i 95- 219 <br /> Street Number Direction Streat Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SU9et Number Stree!Nome <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# O 6 GO S o S' 2 LANG USE APPLICATION IT <br /> ( ) 066o5u o <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> C0v1n re 02.3 <br /> CHECKIf <br /> BUSINESS NAME rr PHONE# EXT' <br /> 55 Gnvironrnzn�al Znr- 45 9 - /600 Z116 <br /> HOME Or MAILING ADDRESS FAX# <br /> 766,5- RpclwccJ 1344I 2co $99 - /60 / <br /> CITY NOVA fu STATE/ 4 LP 9 <br /> ?Lis- <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 or <br /> activity will be billed to me or my business as identified on this form <br /> also certify that 1 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,STATE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: -. _ _ DATE: 2-/2- I��/ <br /> PROPERTY I BUSINESS OWNER 13 OPERATOR/MANAGER [3 }v OTHER AUTHORIZED AGENT SCniGr' .S 64 Fa nIre <br /> If APPLICANT is not the BILLING PARTY proof Of authorization t0 sign is required Title � <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 and/or environmentaUsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: �,yr,rr /Z(rnr'J` War{C �/G ('I" <br /> COMMENTS: v ttr1u <br /> );rIGlcuSP_ t/e- ,601,41 fern., 'L 5 9Cn 1- 4V /7r"a eIf K• fti v/ WIli re,,:cw C�C_l(� <br /> ?/east 97 on�r Q,✓esf•ons <br /> ACCEPTED BY: EMPLOYEE#: o DATE: <br /> ASSIGNED TO: EMPLOYEE M0tj ! DATE:Date Service Completed (if already completed): SERVICECODE: -+ PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> PaymentType Invoice# Chock# c Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> 07/17/00 <br />