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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> u 57APb S�6 -vii <br /> OWNER/OPERATOR <br /> I Pvl-1,r.r q CHECK If BILLING ADDRESS <br /> FACItm'NAME F—i w c <br /> SITEADDRESS J `�(' D ��Lot \ pd L) <br /> al� (o�- SU"tNumber llo �� ( Zt e CI IV 1963.2—L) <br /> �zp Code <br /> J <br /> HOME Or MAILING ADDRESS (H Different from Site Address) <br /> Stroet Number Street Name <br /> CITY STATE ZIP <br /> PHONE En A N LAND USE APPLICATION# <br /> 32 Z D- C) -0 <br /> PHONE#2 Esc. BIDS DISTRICT LOCATION CODE <br /> I ) i I — <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS itj/( YD I <br /> r <br /> BUSINESS NAME PHONE# En. <br /> �e— //O�� `� <br /> HOME Or MAILING ADDRESS �'J FAX <br /> ;7e7 a ZI Al Ir✓ 7 d ( I <br /> CITY n STATE GA ZIP 16- 3 20 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: DATE: 10 ( 2,02.0 <br /> PROPERTY/BUSINEsSOWNER, OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT <br /> IJAPPL/CANf is not the BILLING PARTY proojojauthoriiation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 <br /> tal/site assessment <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ArAy�e_time It is <br /> provided to me or my representative. ICt A <br /> TYPE OF SERVICE REQUESTED: ED <br /> COMMENTS: ``II00 SgN J 0 12020 <br /> 1VC,W 1} d yFQiTN4 Pq RAl <br /> VVV 1. <br /> NT <br /> ACCEPTED BY: /' 6AI"4 EMPLOYEE#: DATE: <br /> ASSIGNED TO: h EMPLOYEE M g� DATE: <br /> Date Service Completed (Iralready a leted): SERVICE CODE: D(q Pi E: I(A2 <br /> Fee Amount: r�-(/U Amount PaIg/s D Payment Date A911 AD <br /> Payment Types _ Invoice# Check# / z() Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> ?4%01e 5 S <br />