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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/0 FIRATOR CHECK If BILLING ADDRESS❑ <br /> Ur )n ekez <br /> FACILITY NAME SITE ADDRESS <br /> Lc) �I 11-52- 15 IUen!co <br /> treat Nama Cll ZI Cotle <br /> NOME or MAILING DDRESS (If Different from Site Addres�s1) Cf5�7 <br /> I.5 Sit salt Num6talr Street Name <br /> CITY S STATE A Zip GS 2-I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# f <br /> Qo`l) yOl S8y6 <br /> "O'E' EXT• BOS DISTRICT LOCATION CODE <br /> ( 2dq) 6 y I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR (1 , CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME �� `� P Tr)4) V 0 / 5E 6/6 E'tT <br /> HOME orMA LING ADDRESS FAX# <br /> v x S Lt✓O ekl G A Ol 5 2 ( ) J <br /> CIN k-1 STATE 614 ZIP tlS (S <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: /1'V477L/ p .Si,Ive) l e a DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT 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: M <br /> COMMENTS: <br /> 4AR �Fo <br /> 19 <br /> CO <br /> H HOF gyRNo?tY <br /> T <br /> ACCEPTED BY: EMPLOYEE#: qg-,7-7/) DATE: , <br /> ASSIGNED TO: EMPLOYEE#: ✓ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> f -2 <br /> Fee Amount: W Amount P i /S�?• oa Payment Date Z Z J <br /> Payment Type Invoice# Check# Re'ceiv By: <br /> END 4SR FORM(Golden Rod) <br /> REVISEDED 1111 11/17/2003 <br /> i <br />