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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � SERVICE REQUESTOR <br /> OM nQ(lL4J <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSO <br /> FACILITY NA Nni�I ?,2 /' 4�7s ®� <br /> SHE ADDRESS <br /> Slreet Number Direeaen d' Sir X/ a ,C C' SIF Zi Code <br /> HOME or MAiLING ADDRESS (If Different from Site Address) A lie T <br /> Street Number Street Name I V! I <br /> CITY STATE ZIP <br /> PHON M EM. APN# LAND USE APPLICATION# Or10 <br /> (M) -AVoo-17.37 Sq KnOA L <br /> Aj <br /> PHONE#2 Ear. BOS DISTRICT <br /> Y <br /> l ) AaQK gR7711 L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 141ki� CHECKHBILLINGA <br /> DDREExSrS <br /> BUSINESS NAME PHO $ <br /> /q_ //)/�✓ — -7o'7 <br /> HOME or MAILING ADDRJ ,,, FAX# . <br /> 416)ate'' <br /> CITY —h ✓29 STATE � .. ZIP y <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 1 have prepared this application and that the work to be prformcd will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FIDE taws. <br /> APPLICANT'S SIGNATURE: r DATE: /Z,�t�OL'D <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AG.' r , <br /> IrAPPLICANT is not the BR.LING PAR 7Y proof of authorization to sign is required rule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: y� <br /> COMMENTS: SPS 1 '�� SpIL ._. ;;C.f}Lt'IS L L'. 4I✓�.° <br /> C i � 1 ` <br /> ACCEPTED BY: EMPLOYEEM 2( DATE: /L <br /> ASSIGNEDTO: EMPLOYEE `JA 3 DATE: LP '^' <br /> Date Service Com eted (if already completed): SERVICE COODDE�: 2I PIE: 3 b <br /> Fee Amount: (� Amount Pal 3�CL co Payment Date J 2'D <br /> Payment Type 41dQd,'-/- I Invoice# Check# b775 �,6 Received By: <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003 e _. <br /> P <br />