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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 /> ri 1�'�Z' CHECK If BILLING ADDRESS <br /> FACILITY NAME V_/E S T E 11L N T f✓f-- <br /> SITE ADDRESS 3 3 3 3 .S N u/y q C( ST p G'k TO to79S Z 1 5 <br /> Street Number I irection / Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zaq ) ` 'y7 - ZS(OS APR 2 <br /> PHONE#2 EXT• BOS DISTRICT SA �gQUICODE <br /> N COUNT <br /> CONTRACTOR/ SERVICE REQUESTOR HEALTH DEPARTMENT <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E <br /> C-,2a�F flfv��o�Pr� � "� 2bl� '2�Lt7 -253 <br /> HOME Or MAILING ADDRESS FAX# <br /> s <br /> S. S TOC,fcTo,0 AV'-F-. ( ) <br /> CITY e� ( �1 C r-1 STATE GA zip G� <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 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: &��< u DATF: 1! 112PROPERTY/BUSINESS OWNER❑ OPEERATOR i MANAGER 1:1 OTHER AUTHORIZER AGENT v O T£�t `L�O�✓J T <br /> If APPLICANT is not the BILLn'G 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: 5 E P'n r✓ N S F f-e- 10 <br /> COMMENTS: 2 �1 US —�'�j C, <br /> ,JotJ -f% GV,� (, RvvaJ 1) 5f-I?-1ckC__ <br /> -fit V phi <br /> DfF �,N 0L�(U5JW2V <br /> ACCEPTED BY: v V\j EMPLOYEE#: ���l/l DATE: �/_ ' Z�y <br /> ASSIGNED TO: Lit EMPLOYEE#: L'u" ;rZ/L DATE: r <br /> Date Service Comp ted ( already ompleted�r): ` ,o SERVICE CODE: C) PIE: `f Z6,'2 <br /> Fee Amount: Amount Paid �,(j�, Payment Date `t <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />