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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> «rl3 E� .S�9T/�i/ `7 L�✓/�FI 3�--,0094--ego S <br /> OWNER i BPEMWM <br /> BILLINGADDRES® <br /> FACILITY NAME C2.gL / `/.� / �J� /// ✓U /��G4J� `✓ <br /> SITE ADDRESS3//3� ;P5 2 77 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /e1c <br /> Street Number Street Name <br /> CITY �.-.. / STATE G,, d ZIP7�}S.)p c <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# .J <br /> (.�10) -�14M-70Z ,6 2 $ 3 ®3 0 /o <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( ) <br /> i <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR g -L �• �v`L <br /> `✓ �"� � CHECK If BILLING ADDRESS <br /> BUSINESS PIAMEP u�� C��N� �/�,...�UZID PHONE# �b <br /> �? Q Y ,G✓,9SiExT <br /> 6 <br /> ,to3 <br /> F(9iMEllrMAILINGADDRESS / ® V� G/ (;?"Y) 1(7 ® 3o 7 <br /> CITY S';U x 707t--1 t5 STATE (jl4 ZIP �v 5-2—cr7 <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 i <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 RAL laws. <br /> APPLICANT'S SIGNATURE:moi! �.�r Gt'�2GCi DATE: �r o 7 _ / /- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:_ / /�Q ,r- <br /> COMMENTS: f>RIUM ���I�/% 6�/a�GG�I✓� IGS/7/�� j /QJQ'l I <br /> /(24107 c <br /> ACCEPTED BY: >/ v c EMPLOYEE#: 441'9.0 DATE: 1!1A,10-7 <br /> ASSIGNED TO: �'�I-z P EMPLOYEE#: p� DATE: ,9/FJ', I <br /> i <br /> Date Service Completed (if already completed): ZQ 7 SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> I <br /> i <br /> 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i' <br />