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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# I <br /> t!���v ,��✓/i'�Ry Cllvv'a4t V-s/=4 ego 5 .j Zoo 53-5 <br /> OWNER/8Pelb9fMCH CK BILLING ADDRESS® <br /> A-�✓ ��'QtlirtJ �4utiiy—�u��/l1✓U�t'.�1 ,�E7ai —.,S"Jzlt� �,.�T7�� <br /> FACILITY NAME /6TI?,-74 <br /> 17W ! <br /> l/ <br /> ` ,rte_ <br /> -?//-To /�,,//�dL�7✓ OC <br /> SITE <br /> SITE ADDRESS <W71-1 G'!/• ��•�L J 17 °' ` >� 7'e4i `®"�R�C`� J"5.3 -77 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY ,j „-.. / STATE d ZIP -0.5 <br /> PHONE#1 /c- EXT. APN# LAND USE APPLICATION# <br /> d 2 $ 3 030 /0 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> i <br /> CONTRACTOR. SERVICE REQUESTOR <br /> REQUE$TOR /C`��y�t'L G•/tll,�hp(��+L <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME (� 1 � G N�� 'Q//✓A ^"k41 <br /> � PHONE <br /> � �30� <br /> Y <br /> H9MEer MAILING ADDRESS �e ® OrN G/ {X 09) t/� -" �® 7 <br /> CITY �vtll.�/Oh/ 6 STATE tZ'IP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, i <br /> acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project j <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 FE RAI,laws. <br /> APPLICANT'S SIGNATURE: DATE: a j _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �� �Vd�- /��G <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 i <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:- <br /> COMMENTS: .aRM41^/ ���I�/% ��Q�CG//✓C, %_C./J?PGR `� <br /> 42 <br /> { <br /> ACCEPTED BY: yCr Q V <br /> EMPLOYEE#: I�d� DATE: �✓ �o� <br /> ASSIGNED TO: ` ^� � � �` ` EMPLOYEE#: 41/`&0 DATE: <br /> Date Service Completed (if already completed): 1112-1710 7 SERVICE CODE: P 1 E: 7 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> 4 <br /> EHD 48-02-025 SR FORM(Golden Rod) ? <br /> REVISED 11/17/2003 <br /> i <br />