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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Prirpertly, 1 FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR \\A OW\ fN IC) (i NY <br />CHECK if BILLING ADDRESS <br />FACILIFY NAME <br />SITE ADDRESS 3Qualr . <br />Direction -ft70 1 <br />M(A IN Ga 122/() <br /> <br />HOME or MAILING • 1 ' . ' ifferent from Site Address) <br /> <br />Or po f 1 . <br />Street Number Street Name <br />CT' STATE ZIP <br />Err. <br />PM() 1141) ng.goov <br />APN I <br />tRy,_No-io <br />LAND USE APPLICATION # <br /> <br />HONE it2 Err. P ) BOS DisTincr ( I LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR ,a.A._.\\ \\1\0$6\\\c CHECK if Ba.upin AcroaessA <br />BUSINESS NAME \\I\ Ck ca) \ \c <br />1 <br />01/1 \\ vi 0 Inc PIA g- 112,T- <br />HOME Or MAILING ADDRESS m f\w,e}R v{A . \s. FAX t <br />( ) <br />CITY \\A Van STATE GA) zip I q--5-7 <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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TA and FEDE laws. <br />APPLICANT'S SIGNA : DATE: <br />PROPERTY / BUSINESS OWNER RATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />-APPLI is ol the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, thc 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 OP SERVICE REQUESTED: -.7, j ' C ‘0A v\ to le, \,wi\o/nyly1 pft.){/fligrp y <br />COMMENTS: Nc1\4\00i ...0 <br />W() <br /> <br />NvyA v011 i/COC) slci-olls-- <br />;`1 1 i <br />imcKcs for( NzIN Y\ <br />, <br />ov! to cit/4 <br />iviAAlly <br />,SAN j , 4 f g-, L.,,4 n, ,, <br />i 1-1,4ZrviRcjAyiliy coot <br />ACCEPTED BY: . t,tk j7) EMPLOYEE it: tAlit DATE: 5 / -7 M IL, <br />ASSIGNED TO: ;./,/)k.f.i. 0 vi (...44 EMPLOYEES: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c, 6 P1E: 4in i i <br />Fee Amount: /5-02 .6D Amount Pa /52., oD Payment Date ,51-7 /2 ,• , <br />Payment Type - Invoice # .Check # 723-536 76s Received By:X <br />END 48-02-025 <br />REVISED 11/17/2003 <br />17c OiS 3C) SR FORM (Golden Rod)