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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q14 /4l a/U5Te fa L /6 <br /> OWNER/OPE TOR <br /> r G e/� �M /Bft -1 ✓ <br /> Q <br /> FACILITY NAM ^ CHECK If BILLING ADDRESS <br /> �1 C_ <br /> O Y Pr Poly ,$' OWve?� <br /> SITE ADDRESS/��/ / <br /> // Street Number �on `7-�Street Nart� CRY Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) ,NQ <br /> 11 ?1:90 Street Number Street Name <br /> CITY AM el 4jql" STATE„ zip G <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRE <br /> S v r cl <br /> BUSINESS NAME PP EXT. <br /> rP® Lr� �.Hv/ro��-r�-++?� -��r c (V 6Z 3 <br /> HOME or MAILING ADDRE}§�S FAX# <br /> ,' <br /> e4t 44-f 41-sr <br /> CITY G W-1 f STATE i/ ZIP / 5-3 J^ <br /> BILLING ACKNOWLEDGEMENT: L, 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 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: DAT IES -7117�/3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 1 MANA R ❑ OTHER AUTHORIZED AGENT JX� G®7�SG� /•�+ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 /> i <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: R <br /> MENT4%A1r <br /> COMS: G r,7- I JUL ' a /0 <br /> 13 <br /> ACCEPTED BY: a<��.^e %�arc EMPLOYEE#: Ytr" DATE: 7//7//3 <br /> ASSIGNED TO: �a.� Y EMPLOYEE#: Z/4,.'D DATE: -7117113 <br /> Date Service Completed (if already Completed): SERVICE CODE: 30� P/E: <br /> Fee Amount: (>a1S' Amount Pai 6;5,0 6 Payment Date 7 7 <br /> Payment Type Invoice# Check# �`SZ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />