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� f 1 <br /> SAN JOAQUIN COUNTY EN«tONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P.IeS'►Ile n+ta t N 0 <br /> OWNER/OPERATOR , ,1* Y1A I <br /> 0.t.L►'l 'V l 6 4 1'M 1t-C-f t ( ` CHECK if BILLING ADDRESS <br /> FACIurr NANE (( / <br /> SITEADDRESS gS LJ Fnk rAlt P-60-0( L.ocCt gSZY2- <br /> Street Number Name city Zw Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Q D O X -70 <br /> Street Number Shyd Nam <br /> CrrY A sT_t►�E ZIP 9SZZD <br /> PHONE#1 ExT- APN# LLANID'tUSE APPLICATION# <br /> (ZOV 97t - Ll+7s pagDaoo-7 <br /> P��R) `- - I J Ext. BdS DISTRICT L LOCATION CODE <br /> t0 r <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REouESTOR ) au rt M y'rr i j( CHECK if BIL umr ADDRESS <br /> BuswEss NAME^- PHONE# �^ <br /> HOME or MAnsm ADDRESS FAX# '`1 M�'•T <br /> ( > C/ FD <br /> CITY STATE Zip JU q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedft"��tJ/Qn(Q�f same, `020 <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wit�flCLLS IRON <br /> or activity will be billed to me or my business as identified on this form. l"CAL''�rTL►11ti`p NMENTq�TY <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 RTMENT <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �J <br /> APPLICANT'S SIGNATURE: 7�, �t-Y DATE: &/27—f"ZZS <br /> PROPERTY/BusiN ss OwNERP OPERATOR/MANAGER❑ OTHER AuTnoiuzED AGENT❑ <br /> IfAPPLICANTis 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: ff <br /> CoNrENrs: S�P.�I`a SysFY,,-►� t,..cca`E-ic�n v�r��,�a�on �tvt" ri�w SwinlM,Ing <br /> POO( C-0VX5rUd�0yx, VerIf 10fvfIZ41 'odiiecioy, (5tSFF)J(' <br /> tivies Car 14A w'► west sitar e f pp,*. Pool to bF 6t�ed %7„ }yf S;x,17�1 <br /> s i'0 oose. <br /> ACCEPTED By: EMPLOYEE#: DATE: <br /> 6 d3 ,,?ado <br /> A--MGNED To: VC EMPLOYEE#: DATE: {h3 O <br /> Date Service Completed (if already completed): SERVICE CODE: ©` f PIE: yd�d <br /> Fee Amount: 5a Amount P �� Payment Date 2 <br /> Payment Type Invoice# Check# � O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />