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Jv� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHOEPAR;711NT CP <br /> SERVICE REQUEST 0 <br /> Type of Business or Property FACILITY ID# SERVICE REQ ST# v✓\ <br /> -41 <br /> OWNER/OPERATOR <br /> A CHE/Clf <br /> BILLING ADDRESS O <br /> P11/OY\ I n�Jv LeTr V <br /> FACILITY NAME <br /> P�1 ffl7`� <br /> SITE ADDRESS u��� (�lJ GL-�? o v �j <br /> Street Number Direction Street Name city Zip Code <br /> �� <br /> HOME or MAILING ADDRESS (If Different from Site Addre.p v <br /> I"Oo,i Street Number Street Name <br /> ITY NATE LIP <br /> Gin G�� 94563 <br /> PHONE#1 ExT. =0 <br /> PN# A <br /> D USE APPLICATION# <br /> ( ) p ( <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTO / SERVIC REQUE(STOR <br /> RF�QOESTOR G YlP 1 e YY G 0\P7�f/v�CD°✓ <br /> r CHECK if BILLING ADDRESS0 <br /> BUSINESS NAME PHONE# EX' <br /> PPYr C- 91 y to 9bYr� <br /> HOME or MAILING ADDRESS FAX# <br /> o -mo S '1�e S ((1lb) �' <br /> CITYQ ►'Q rV�C't'� <br /> tc STATE CA ZIP q5 -�c <br /> <. <br /> BILLING ACKNOWLEDGEMENT' , the undersig ed property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or proje t specific ENVI NMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or m usiness as id e tified on this form. <br /> I also certify that I have prepared is application nd that the work to be performed will be done in accordance with_all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta ar TATE a d FEDERAL laws. / <br /> APPLICANT'S SIGNATUS/13�r <br /> PROPERTY/BUSINESS OWNE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT n�I(,��✓, S7Gr J <br /> IfAPPLIC NT is not t LLING PARTY proof Of authorization to sign is required Title <br /> AUTHORIZATION O RELEAS INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, ereby autho ze the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the YAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a a time it is <br /> provided to me orply represent ve. <br /> TYPE OF SERVICE(IEQUESTED: 1 —ZA <br /> COMMENTS: SAV Jp �Q14 <br /> ��VtN COU <br /> ACTH OE�� O NfY <br /> MFNT <br /> ACCEPTED BY: 17 VL EMPLOYEE#: DATE: <br /> ASSIGNED TO: i Y—!� �,, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: 2302' <br /> Fee Amount.` z�`� Amount Paid 37S. 07 Payment Date S� 3 <br /> Payment Type Invoice# 16z Check# 3[ Recei ed By: <br /> EHD 48-02-025 ° 'r `6 D Z� ' c SR FORM(Golden7f\1,1 <br /> REVISED 11/17/2003 <br />