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6-1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dt,PARTMENT <br /> SERVICE REQUEST f� 2 4 <br /> Type of Business or Property FACILITY ID# / SERVICE REQUEST# <br /> Ae s SK OaS3VIL4 <br /> OWNER/OPERATOR <br /> ,,ns, CHECK If BILLING ADDRESS Er <br /> FACILITY NAME <br /> SITE ADDRESS ,34ae /X/ CyE9k11- A0 A ✓EiVGfT STOCJ�ON g�a1 <br /> Street Number Direction Street Name Ci Zip Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P0 . O x Street Number Street Name <br /> CITY <br /> 'gG k C7 STAT�F^ ZIP / <br /> PHONE#'I ExT. APN# LAND USE APPLICATION# <br /> 734 d zoo- t64 PA-;7-1 o i2 a <br /> PHONE#2 Err. BOS DISTRICTLOCATION C <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS D <br /> BUSINESS NAME PHONE# ExT• <br /> (ao - s <br /> HOME or MAIL I ADDRESS FAX# <br /> o ( ) <br /> CITYSTATE01A ZIP 5-3 <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 app ' n andth work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T and FE RA ws. <br /> APPLICANT'S SIGNATURE: kvADATE: 06'A6 a'g <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ O HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of auth ization 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: SS�/G �VJ 1=[AlF <br /> COMMENTS: �� k® <br /> SAN jo 0 6 2a22 <br /> Bly QU/ <br /> HE,q�do f Cn°r[J 7'' <br /> ACCEPTED BY: ��J L lj EMPLOYEE#: DATE: <br /> ASSIGNED TO: k` EMPLOYEE#: DATE: G 6 aoZ <br /> Date Service Completed (if already completed): I SERVICE CODE: s"R-3 P/E: a 6da <br /> Fee Amount: +6 a� I <br /> Amount Paid 41 r0/�('�l Payment Date /0 <br /> Payment Type �t �p/ Invoice# (VOR <br /> ��� Rfeceived�By:U&17� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />