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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> . SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /I"A) fe S F=A C9 00 -Z y <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 1rt/cA� e v � o N <br /> SITE ADDRESS ,¢ 3 a7A/, _ vu 1 /-s 6 N �'✓!x y 510 c �C7�oN 9 s2 4 5�" <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 173+ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> � l< Cc, T CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> o /vTrccc�oy-s paqq ) 4 6, / -63:3 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 S3s- N.. D v- , (Ac)9) 4 6 / - t1, 3 f .Z <br /> CITY S 7—C G kJ /V STATE �p ZIP C15-,;z �s <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 or <br /> 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: r DATE: ©S— D.5-- D 4 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGE OTHER AUTHORIZED AGENT)K,SCx l e S /�N r <br /> If APPLICANT is no t e BILLING PARTY,p o of authorization to sign is required Title Y i�� (�l <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property lotate#ii�&D <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 t4eat 2006 <br /> provided to me or my representative. r <br /> c SAN JO UNTY <br /> TYPE OF SERVICE REQUESTED: ( / p ENVIRONME MEM <br /> COMMENTS: T oL s 2 -9 14 0- 5 S e Y— tJ�i�/V e /�5o C 6- d S d-� <br /> Q a. lL w 0.5 / 6 C a. Te- ct 65 2 2 '-'x77 tom c G> /2 G'�r a uJ <br /> GQ Iv rrt t h e fit u v e 4 .e e ill Ca /v - ►" a cO To <br /> 6 re d6 C Cn c le Ct_ NJ r.� 1^ � a Y a oY— f- i e <br /> ACCEPTED BY: EMPLOYEE#: l f� DATE: <br /> ASSIGNED TO: Nyo--/ u EMPLOYEE M [� /;, Q DATE: <br /> Date Service Completed (if a r ady completed): SERVICE CODE: P I E: 2 <br /> Fee Amount: C"DAmount Paid a'? rj C) Payment Date !Z!D <br /> Payment Type ✓' Invoice# Check# ID 757t? Received By: <br /> EHD 48-02-025SR FQFtM(Golden FFod) <br /> REVISED 11/17/2003 <br />