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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CNECKN <br />FACILITY ID g <br />SERVICE REQUEST # <br />Gas S t t. n <br />Dr, SU: tt-17 <br />FA Dc's <br />CITY n r <br />-5 376 <br />OWNER / OPERATO <br />N *. <br />DATE: -2 2- <br />CNECK if <br />C- -�; c- <br />v n; enn Eve <br />-IS I S <br />FAaurTNAME GrrdQ. K .2106-y <br />Fee Amount:3 `1S <br />SnADOREss 320? <br />91040 <br />1 W <br />0118COM <br />I NQrnmer Lone. <br />S-tocKton <br />I My <br />7 <br />HOME or MAIL=ADDRts3 (R OMhr«k ham Sia Address) <br />Received By: <br />S gme - <br />CITY <br />STATE ZIP <br />PNOK E1 EXT. <br />( 1 <br />APN # L.Atw USE APPLICATION 8 <br />PH=02 EM. <br />EM DMTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR 11 <br />REQUESTOR <br />n `� C' w n <br />CNECKN <br />BUSINESS NAMIE <br />ler- Son n <br />PH=# Bre. <br />S) -7ssS <br />HOME or MAILwo ADDRESS <br />31`(0 C-c4pip <br />Dr, SU: tt-17 <br />Fm # <br />(9 .Sl SS/ -y770 <br />CITY n r <br />STATE GA . LP IS -6 7 <br />BMLING ACKNOWLEDGEMENT: I, the undersigned property or badness 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 JoAQu N <br />CouNTY Ordinance Codes, Standards, STA FEDERAL laws. I j <br />APPLICANT'S SIGNATURE: DATZ: - ! � 2 / 10 <br />PROPERTY / BUSINESS OWNeRO oPCRATOR / MANAGER (3 OTHER AuTnov=D AGENT Con t rc, C- f r - <br />If APPLiC4A7 is not the BILLING PARTY proof of amtborization to sign is mquimd Titre <br />e1TI HO IZATION TO RELEASE INFORMATION: When applicable,1, the owner or operator of the property located at the <br />above she address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQum CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />Dmvided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />Comums: <br />('"loci. �;Cct:On Perm: t to <br />a:sper%ser Pan Sens4rr. 5:+e— <br />Cha. fl . <br />;rt.fta,tl new 1le�Lder (toot <br />Inotr us: ng Qr4vo f loaf- t, <br />ACCEPTED Or. ^ <br />EYPI.oYEE i«: 4L� (o <br />DATE: Z 2 �, 4 <br />AssxmD To: <br />4� <br />EIIIPLOYEE /: L161 <br />DATE: -2 2- <br />Date Service Completed (if already completed): <br />Sffm Coos: <br />E: <br />PA: <br />Fee Amount:3 `1S <br />Amount Paid 13 �{$" o= <br />Pint Dab <br />,Z' 2 ? / ! e, <br />Payment TypeC.ed.t <br />Check d <br />Received By: <br />EHD 48-02-025 ` �a�f * A y 6 9 3 S SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />