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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICpE/REQUEST# <br /> FGAMa.w j i_CQ- V:>Y- gov 00� 7's <br /> OWNER/OPERATOR <br /> Ni r�c P h,I(on CHECK If BILLING ADDRESS <br /> FACILITY NAME1 u)cj-- p n <br /> SITE ADDRESS 126 1 V�/- N( 1 t'1 ��, _ n pry F 1 poi•-) C, <br /> 1 Street Number Direction S reel Name `•EJ City <br /> ZJ Cod9 <br /> HOME or MAILING ADDRESS (If Different from Site Address) 15" tf,10 rl� C I f C(e- <br /> Street <br /> eStreet Number $tro9t Name <br /> CITY 1 On STATEC,,,,_ Zip '75-,S37 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (zoq) (ol 2-758/ <br /> PHONE#2 ExT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORC/gn/G�B *VAP �pr <br /> /`� a rcA y." Z,--2qU i t t p o 7(� H CHECK If BILLING ADDRESS <br /> A, <br /> BUSINESS NAMEPHONE# EM' <br /> Gavy ►'1c _ 621*) 2¢:S _SR'S <br /> HOME or MAILING ADDRESS FAX# <br /> o Cor o roL+e Chr, pr i�2r S u► e. 550 ( ) <br /> CITY Mort-IC-rL RaKrSTATE 01 ZIP q1.7 <br /> BILLING ACKNOWV EDGEMENT: 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: T DATE: J 21 U <br /> PROPERTY/BUSINESS OWNER❑ OP ATOR/MANAGER i OTHER AUTHORIZED AGENT <br /> IfAPPLiCANT is not the BILLING PARTY,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, 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 ti `t.. <br /> provided to me or my representative. Af�� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Ro <br /> t-2- �( <br /> -(o -i c l c,'ln iZ a vt c jC s,�, 201 <br /> ry <br /> cS v l�b�, u� , ( f GP Q(,f w� (�"' H Tti po PIJ AQUM, O�4 <br /> (l v� G 3_ --t _ f ! qR MsNT <br /> ACCEPTED BY: EMPLOYEE M DATE: S --�k—��j <br /> ASSIGNED TO: EMPLOYEE M DATE: /� <br /> Date Service Completed (if already completed): 1 <br /> SERVICE CODE: S Z P I E: (o O <br /> Fee Amount: Amount Paid)q/7�6, 22q Payment Date l <br /> Payment Type , Invoice# Check# Sg�J /�/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> _ �-3 0 14 <br />