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SAN JOAQUL11`tOUNTY ENVIRONMENTAL HEALTIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �pERVICEREQUEST# <br /> -7kCO // Y <br /> OWNER/OPERATOR / _ <br /> CHECK It BILLING ADDRE55O <br /> FACILITY NAME rrr"'LLL ///lll CSO <br /> SITEADDRESS -777.S� /V. r"'Cy LCL Ta ay 5s-ioX/ <br /> Street Number Direction Slreet Name I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> s , /G Ce GL GJ L <br /> /-f GOL4�'trt Street Number Street Name <br /> CITY STATE ZIP <br /> 11jeI.;-e2— <br /> PHONE#1 EXr. APN# LAND USE APPLICATION# <br /> (1/y ) G7/ T3S'�9' <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR LSa�f@ <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> GHK <br /> BUSINESS NAME PHONE# EXT. <br /> tia !o re- I qlI6 e14, e, C po <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 4G'"-.w.....,.lD STATEC-J L•T ZIP 9S-8-�9 <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 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: <br /> T <br /> PROPERTY/BUSDVESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN'r�' G'O hT4 e7 Y z G <br /> IfAPPGICANT is not the BILLING PAR TP 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 time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> DEC 2 7 20" <br /> SAN JOAQUIN Tri <br /> ACCEPTED BY: EMPLOYEE#: 1DATE: <br /> ASSIGNED TO: , EMPLOYEE#: 2 DATE: (/ <br /> Date Service Completed already completed): SERVICE CODE: PIE: Z� <br /> Fee Amount: ' Ciro Amount Paid fl� 31 j p-a I Payment Date ZfZZ <br /> Payment Type Invoice# Check# rL-7 S5?La Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />