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SAN JOAQUINIOUNTY ENVIRONMENTAL HEALTH APARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS® <br />FACILITY ID # <br />p�p,YM p <br />SERVICEREQUEST # <br />o ! <br />S�rvi GQ .�71i`f"i Y <br />�I ` ! <br />HOME or MAILiN ADDRES <br />A d. fo.� G�3 ! <br />11 <br />` <br />'� ' l <br />OWNER /�OPERATOR <br />/v4 ✓7 G C <br />STATE C 'ZIP <br />CHECK if BILLING ASSS ❑ <br />FACILITY NAME <br />SITE ADDRESS <br />/� Gn 7f'1i e <br />Street Number <br />Direction <br />' Street Name <br />oEPAR'T <br />ON <br />40Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />015 <br />DATE: '?j �� .v 7 <br />ASSIGNED 70: <br />Street Number <br />D � S 3 <br />St et Ne se <br />CITY <br />STATE zip <br />PHONE#'f ExT, <br />APN# <br />Fee Amount: 2� <br />LAND USE APPUCATION# <br />(:.0-q) ve;z — 7 e.2. J <br />Payment Dateot <br />d <br />PHONE#2 Exr. <br />( ) <br />invoice # <br />SO$ DISTRICT <br />Locmioti CODE <br />CONTRACTOR / SERVICE R.EQUESTOR <br />REQUESTOR� <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />•ori <br />p�p,YM p <br />PHONE# r� Ems' <br />7 % � <br />hurn <br />HOME or MAILiN ADDRES <br />A d. fo.� G�3 ! <br />FAX# <br />t6ts t l 363- `�' <br />/ <br />Circ f� 2 r r --Y ;Gf <br />STATE C 'ZIP <br />BILLING CKNOWL DGEMENT: 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 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, Standarch, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: "`" ? DATA'.: 3 " `? <br />PROPERTY / BUSINESS OWNED ❑ OPERATOR /MANAGER © OTHER AUTuopizED AGENT ep a nayFi un Y / <br />If APPLICANT is not the BILIN_ G PARS 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 erivironmental/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 />rovided to me or m re resentative <br />p Y p <br />r; <br />p�p,YM p <br />TYPE OF SERVICE REQUESTED: GPC- Y-1. f <br />COMMENTS: <br />SAN JOA �NMETA <br />ENViR <br />oEPAR'T <br />ACCEPTED BY: N <br />EMPLOYEE #: <br />015 <br />DATE: '?j �� .v 7 <br />ASSIGNED 70: <br />EMPLOYEE #: <br />D � S 3 <br />DATE: —cI a % <br />Date Service Completed (if already completed): <br />SERVICE CODE: I !� <br />P i E: 23 0,do <br />Fee Amount: 2� <br />Amount Paid <br />S <br />Payment Dateot <br />d <br />Payment Type �f S <br />invoice # <br />Ct�aeic # <br />C,l i <br />Received By: P( (y <br />EHD 48-02-025 5R FORM (Golden Rod) <br />REVISED 11117/2003 <br />0 <br />