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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ow i-2 8 (p co:�)5°1 S <br /> OWNER/OPERATOR <br /> as Q � � yk 4`CI 1' CHECK II BILLING ADDRESS <br /> FACILITY NAME t 0't (-'I�ve C+G Y- IA r o,Q-� �I <br /> SITE ADDRESS 1 1 LIST S J �l I((�/' DLI Q V S -- 5'�{C k I o� 9s'ZGtr— <br /> Street Number 'e o "' tee Name City <br /> T'-' ZI Code <br /> HOME or MAILING ADDRESS (If Differ nt from Site Address/)'p <br /> 5 O V Street Number Street Name <br /> CITY STAT A ZIP S <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (toy ) 2— - �tyl9 <br /> PHONE#2 EIT, BOS DISTRICT LOCATION CODE <br /> (2a9 ) 29 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - l n „_ �-_1 I�.I va^ A <br /> y f'C✓` (�L /'� CHECK If BILLING ADDRESS <br /> BUSINESS NAME rl p R PHONE# EaT' <br /> HOME or MAILING ADDRESSFAX# <br /> EL 'S <br /> 2 OJOIW, 9R✓I 01-l2 ( 1 <br /> CITY O C O 14 <br /> &_ STATE ZIP 2-1 b <br /> BILLING ACKNOWLEDGEMENT: 1, 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 apphca ion aq that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E t EDERAL laws. —, <br /> APPLICANT'S SIGNATURE: DATE: -4D3—Z W <br /> y <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /J'APPLIcANT is or the BILLING PARTY pro jo 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T-LOCA m <br /> COMMENTS: <br /> Giwl vtc�( 4 0 JAN 03 ?!I?0 <br /> H� RpIUyME oUty�, <br /> DEpgR � <br /> N r <br /> ACCEPTED BY: �, (/1/\AA I A te, EMPLOYEE M DATE: 01 -19AefZD <br /> 1 <br /> ASSIGNED TO: ` .�/p T/tv� e J EMPLOYEE M DATE: V 7 6���-U <br /> Date Service Completed�(if�already completed): SERVICE CODE: Q� PIE: I,'2 <br /> Fee Amount: SZ — Amount Paid �' Payment Date 3 26 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> r <br />