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N <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />n (yF�ACILITY IDD # <br />W 1'92&1 S <br />SERVICE REQUEST # <br />`^ Vim 5 C_ - <br />OWNER /OPERATOR )/GI n( ,n <br />� I 0 +(_� <br />CHECK If BILLING ADDRESS <br />/ ,)/ <br />FACILITY NAME O � 'r� M J uC n <br />1I 1" 1' ll(/jr�l�. `P/a <br />SITE ADDRESS I '^'�0I <br />Streeett Number <br />Direction <br />�1� <br />Strael Name <br />r� /� <br />' Y Lei M�DI <br />Cit <br />p� <br />S_3S I <br />ZipCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />; 001 <br />Street Number <br />G+,l pa ot p f . <br />�" Il.. Street Name <br />CITY ,/�/1 OGL /)C� <br />r 1 UC <br />STATE ZIP /il ir'jS' <br />PHHONE#1 Exx' <br />(hey) 2 . <br />APN # <br />AsSIGNEDTO: <br />LAND USE APPLICATION # <br />PHONE #2 EXT• <br />DATE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ,pA '^•`^ + �n f^ <br />1/tilr' (�L l/rL/TI CHECK If BILLING ADDRE55E] <br />BUSINESS NAME 0,�y.,� u/1 <br />r Vt/V lJ� <br />PHON I EXT. <br />> �J <br />HOME or MAILING ADDRESS �^ /Ja..( 1"��, <br />FAX# <br />CITY STATE ON ZIP 3 S l <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, and EDERAL laws. / �% <br />APPLICANT'S SIGNATURE: 1 DATE: T� Z/ OZf <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT❑ <br />IfAPPLICAAT is not the BILLING PART P 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, geoteclmical data and/or environmental/site assessment <br />infomtation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at dA same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:WNW <br />GC <br />COMMENTS: <br />i j(c <br />0 <br />ZD?l <br />%'IDAQUN <br />MEq��DZ� <br />M NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 12-) <br />AsSIGNEDTO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Com eted (if already completed): <br />SERVICE CODE: [ <br />PIE: <br />Fee Amount: <br />Amount Paid <br />r' <br />Payment Date /6 24 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod) <br />