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SAN JOAQUIN&LINTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Go_ga/r/Nt ,5a_leS <br />PAYMENT <br />FACILITY ID # <br />�r�000�1-72(7 <br />SERVICE REQUEST # <br />'59003% 3 <br />OWNER/OPERATOR <br />S 0. M M <br />S � /V <br />fC <br />CHECK If BILLING ADDRESS <br />FACILITY NAME n! 0- r .�4 V- .. I u <br />(J GL U/ 4 e V N O N <br />PHONE# <br />(g <br />SITE ADDRESS <br />508 w,C40,y7f`ev <br />Street Number <br />S o/ <br />9D <br />Direction <br />4 �, Y �ay <br />arf c <br />Sin Name <br />FAx# <br />(2U4) <br />S T�rN , <br />city <br />ps% O (� <br />/. <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />ENVIRONMENTAL <br />Street Name <br />CIN - <br />STATE ZIP <br />PHONE #1 EXT. <br />0C --I VrE.I <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT' <br />( ) <br />DATE: 3 2-c Q <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR�+7 /� /�O Q ! <br />PAYMENT <br />CHECK if BILLING ADDRESS <br />V Q C / (_ <br />BUSINESS NAME <br />'r /' I TF �iZ <br />PHONE# <br />(g <br />EXT. <br />!f !o!- 6337 <br />HOME Or MAILING ADDRESS I <br />2.5-3S{ //r w Cl AA <br />FAx# <br />(2U4) <br />�(o!-63 J/Z <br />ri^/� <br />CITY S / a c /< / O <br />STATE CA- <br />ZIP r7Sz0 <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 or <br />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 FPPERAL laws-. <br />APPLICANT'S SIGNATURE:95��DATE: O 3- 1 3^ 0 1 <br />PROPERTY/ BUSINESS OWNER❑ PERATOR/M ER❑ OTHER AUTHORIZED AGEN'f/CJ� 0222 <br />If APPLICANT is nit eBILLINGPAR proof of authorization to sign is required Title <br />AUTHORIZATION TO RELlrASE 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. <br />TYPE OF SERVICE REQUESTED: �,S "/— lj ET�fJ F I % <br />PAYMENT <br />COMMENTS: <br />MAR 2 5 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />0C --I VrE.I <br />EMPLOYEE#: 032-f <br />DATE: 3 2-c Q <br />ASSIGNEDTO: <br />SH 11,4 <br />EMPLOYEE#: 73 aV <br />DATE: 3 2S Q <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />L <br />Amount Paid <br />�7 00 <br />Payment Date 3 <br />Payment Type <br />Invoice # <br />Check # 9,2,:z <br />Received By: <br />EHD 48-02-025 R FORM (Golden Rod) <br />REVISED 11/17/2003 - \ <br />