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0 i <br />SAN JOAQUIN COUNTY ENVIRONi'v' MN'IAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />iZ. F --,I— A-( (✓ r U 1^vC- <br />HOME or MAILING ADDRESS <br /><O- 610x, oz.� <br />��-7 0 <br />FAX # <br />((?/&)37;�3- (i'-- <br />rCITY <br />W S N-C�l <br />STATE C. A. ZIP C/S [ c <br />OWNER / OPERATOR <br />Qo l& S -r-c iq TiE C <br />CHECK if BILLING ADDRESS <br />FACILITY NAME G u l t/ �+ � � � <br />K— J <br />/ � �f <br />SITE ADDRESS <br />I <br />(�l L �r►�l� <br />S Tip C (G n ( <br />q S- Z cT <br />Z Street Number <br />Direction <br />Street Name <br />city <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Fi ► "E -(Z P (Z (S /f— <br />S T' <br />S 6 T <br />Street Number <br />Street Name <br />CITY r -7(Z, i:i/I/t G"17-' <br />STATE A zip <br />PHONE #1 ExT• <br />(5-/0) b -00 <br />APN # <br />674 aq,L-)-i_3 <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />I C t4 } /� r" Ct. W TI� T (-T-" <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME LT® v,( G:,K 6, 1 ts-E I, IM 1I.,(.K-J <br />' <br />/Ac C . <br />PHONE# EXT. <br />/,b 3 - I( s Z <br />HOME or MAILING ADDRESS <br /><O- 610x, oz.� <br />FAX # <br />((?/&)37;�3- (i'-- <br />rCITY <br />W S N-C�l <br />STATE C. A. ZIP C/S [ c <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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST and EDE laws. <br />APPLICANT'S SIGNATURE: DATE: i / t{ 1 <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT M d 1 T2 A<�-- <br />IfAPPLiCANT 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: L L r✓W LL <br />COMMENTS: <br />Z pS/agJ / �7 VFFFA - 5 2008 <br />0 5 L; -'A <br />ca <br />SAN ,ioAu,ty c* 0;+� iVIENT HEALTH <br />} LTHDEPARTMENIAtP HMIT/SERVICES <br />ACCEPTED BY: 0 L EMPLOYEE #: C)3-2DATE:Z -y- 0 C <br />ASSIGNED TO: 6 AEMPLOYEE #: 7) DATE: q e <br />Date Service Completed (if already Completed): SERVICE CODE: r P 1 E: _Z30,�> <br />Fee Amount: _ �y- Amount Paid Gi 11 Payment Date -2- IS B 8 <br />Payment Type ✓ Invoice # Check # C� Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />