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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 0 � G <br /> Lo <br /> OWNER/OPERATORC/((/./lo�/l {q��^ <br /> `�/`� 'iii Sr—l�/ eeS GL CHECK It BILUNGADDRESS� <br /> FACRRY NAME CC / <br /> SITEADDRESS <br /> Sheet Numeer n et Neme <br /> CREe <br /> HOME or MAILING ADDRE\SS (Ir Di ferent ,oSite Address) <br /> Sbw., Lv), Street Number <br /> Nam. <br /> CITY �{p� STATE LP <br /> aF—f- .erc MYL�hG� --T-K— :7 s-;, 9, / <br /> PHONE#1 EM• APN# LAND USE APPLICATION#1 'l <br /> (9921 1/02 7`(18 HI <br /> PHONE 92 fir• BOS DISTRICT LOCATION CODE <br /> (2ttl ) Sit 3 ?3c <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKIf BiLUNGAwRFSS© <br /> BUSINESS NAME 1 PHONE# Err <br /> (?l14 Is? 5f - 37�a <br /> HONE or MAILING ADDRESS FAX <br /> CITY STATGkLP <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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an�FEDEy2osl*l�� <br /> APPLICANT'S SIGNATURE: `/iDATE; <br /> �-A <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER D OTHER AUTHORIZEDAGENT,Ga R mlw 6 <br /> xel- <br /> IfAPPL1CANT is not the BILLING PAR 7Y proof of authorization to sign is required T e <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/orlenviroamental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availb pgd at the same time it is <br /> provided to me or my representative. <br /> TYPE DF SERVICE REQUESTED: �� ` C �le <br /> COMMENTS: O VV <br /> y�N <br /> B�l 0 0/ 70zT <br /> T/y0 pqR IV�Nry <br /> ACCEPTED BY: �\ e EMPLOYEE#: DATE: I <br /> ASSIGNED TO: \ O\ EMPLOYEE#: DATE: `(,O_1_V —2 2 <br /> Date Service Completed (N already completed): SERVICE CODE: rul_ I "F: l t,002 <br /> Fee Amount: S 2 Amount Paid -S2_ Payment Date <br /> PaymentType l Invoice# Check# / gS tf Received By; <br /> EHD 48-02-025 <br /> REVISED 1111711003 SR FORM(Golden Red) <br /> , ? azo 52,uzs 6 <br />