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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR f <br /> .� q{s Sqy <br /> I/ -�/`a -wil /� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME aj�,7S G L �J�C� # <br /> SITE AD RE55 e-1•//,t/7/� c r ��f �`4 �� ��L G���v� <br /> Street Number DIrectlon J StreetNam� Clt � l Zi Code <br /> HOME or MAILING ADDRESS <br /> (if <br /> �Different from <br /> rJSite Address) <br /> 0 C✓`'�^ (� Street Number Street Name <br /> CITY, <br /> Z �/ _ -ft) <br /> �TATE ZIP <br /> PHONE M 15/C? ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> -� ���P 5R n 1/C/�n ^ CHECK If BILLING ADDRESS <br /> BUSINESS NAM /`Y t�ii(� �/'� PHONE# ExT. <br /> AC-t15' �G � (57?o ) 31 o <br /> H cIr MAILING ADDRESS FAX# <br /> CITY C)d es G STATE ZIP o�s3sl <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 d FEDE S. <br /> APPLICANT'S SIGNATURE: DATF: lc2 <br /> PROPERTY 1 BUSINESS OWNER OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIcANT is not the BILLING PARTI,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: PA <br /> COMMENTS: Recaveo <br /> DEC 18 2o2a <br /> CNWRONMENTgL71' <br /> ACCEPTED BY: v L�(�j� V /s EMPLOYEE#: 70 DATE: <br /> ASSIGNED TO: /� EMPLOYEE M DATE: / v iL1 <br /> Date Service Completed (if already completed): SERVICE CODE: 011 P 1 E:1!n0 <br /> Fee Amount: S2 Amount Paid l I� Q. 12- 1 <br /> Payment Date J2 -ZL-n v„ <br /> Payment Type Invoice# Check# Received By: �7r� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />