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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S C <br /> OWNER/OPERATOR <br /> O^ CHECK IfBILLING ADDRESSE] <br /> FACILITY NAME caG&guru � o9 <br /> SITE ADDRESS V Z� G�r ; � X10.,/ S�p G�LO� G 9-Z <br /> 3 2 Street Number Direction C Street Name y Cit 1 ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Z Z Street Number Street Name <br /> CITY L STATE ZIP <br /> 5�OG� Y�. ,5-Z I zi <br /> PHONE#t Ext. APN# LAND USE APPLICATION# <br /> (20q) z�aiCo �a0 12211003 <br /> PHONE#2 ExT BQS DISTRICT LOCATION CODE <br /> l 1 M1 `ate <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME t_ PHONE# EXT. <br /> HOME or MAILKG ADDRESS FAx# <br /> Z&7. 7—nr- <br /> CITY C+0 V' TATE zip <br /> 'qSZ i Z <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 <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: )�yar./) Caf.lpyon &',gtlAWez DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is 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 d at the same time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: 7F-OC)� CZyUW t7jrVq�j� C <br /> COMMENTS: <br /> Aq�F� <br /> ACCEPTED BY: 1 , EMPLOYEE#: DATE: <br /> ASSIGNEDTO: `/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE; <br /> '7W D ZJ <br /> -Fee Amount: 152 Amount Pa i 1c>o2 � 2v D Payment Date /2 T <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD n n SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11/17/2003 /-(f <br />