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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />_ Ex'' <br />SERVIICyE; R�EQUEEST# <br />OWNER I OPERATOR \ G I �� t �, a <br />4/l.- '1 ` <br />CHECK If BILLING ADDRESS <br />FACILITY NAME 9 Co e�e G <br />SITE <br />� A'D9DREESS/ �� <br />26.53 MC,/(Ar"Stree�umber <br />Direction <br />�— <br />Street Name <br />O ZZ <br />/ <br />1��/ 11,-t <br />V�ill� C, rtn <br />�ZI�Cde <br />HOME or (MAILING ADDRESS (If Different from Site Address) <br />Z&53 AI)6I�D C-4-- Street Number <br />1 <br />�F•Ja/ja,.rlcf <br />S eetName 2 2 <br />CITY Ua Ite SOD rq5 S <br />STATE ZIP <br />PHONE 91 EaT• <br />(2cnt)G6, 3-( 2 <br />APN # <br />LAND USE APPLICATION It <br />PHONE#2 EST• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR f `� /. ,. ,/ % <br />�'jf,C (n/f2 CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />RA- <br />_ Ex'' <br />HOME Or MAILING ADDRE,s <br />L 3 G( C <br />FAX# <br />( ) <br />CITY ET TE ZIP <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 !pd -that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT EDER <br />APPLICANT'S SIGNATURE: / <br />PROPERTY/ BUSINESS OWNER El� OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1:1 <br />If APPLICANT is not the BILLING PARTY proof of aut%mriw ion 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. pd b. <br />TYPE OF SERVICE REQUESTED: p i4 h kt &U I V\S d-us� , N <br />COMMENTS:f/tN <br />O <br />y EtyViROUIN� <br />o°F^P ro, 4- <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: 10`L2 <br />ASSIGNEDTO: <br />EMPLOYEE#: <br />DATE: <br />O ZZ <br />Date Service Completed (if already completed): <br />SERVICE CODE: Alpf <br />PIE: I �3 <br />Fee Amount: U <br />Amount Paid <br />a <br />Payment Date / 2Z <br />Payment Type <br />Invoice <br />C <br />L�L{ <br />(,��3 <br />Received By: <br />EHD 48.02-025 <br />REVISED 21/27/2003 <br />�fi v <br />�S R FORM (Golden Rod) <br />