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SAN JOAQUI' "OUNTY ENVIRONMENTAL HEAI �'. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REDDEST# <br /> sT QL-j" NT. 5 P-0 0 31 -7 2z <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME /. 1 <br /> SITE ADDRESS <br /> GIC�L.�-S - f Q-S-Gv- (,LS f1E_ MgNi C 9533C <br /> )Z 1 SP Street Number Direction Street Name CI Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) , <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> ( ?p C- 0 G 535 <br /> PHONE#t E%T. APN If LAND USE APPLICATION# <br /> (309) J`"+� - ( q6 <br /> PHONE#Z E". BOS DISTRICT LOCATION CODE <br /> ( 9 ) 6,2 55 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK If BILLING ADDRESS <br /> MLZiT J+ )'f�c S N <br /> BUSINESS NAME PHONE# ' <br /> 12 fv U Su (3 zoo -S <br /> HOME or MAILING ADDRESS /- FAX If <br /> CRYO T S'�U STATE CR ZIP 5?S <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 /> 1 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: � GsC�r -� <br /> DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AuTTIORIZED AGENT❑ <br /> IfAPPLICANT is Hot 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 environmentaUsite 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. •N-� <br /> TYPE OF SERVICE REQUESTED: ..G-�J <br /> COMMENTS: <br /> 9�- <br /> ����\)NN C'- <br /> NG gtor� <br /> EN AONME�`N�P\jHpM <br /> APPROVED BY: EMPLOYEE#: '� DATE: {l 0— <br /> ASSIGNEDTO: EMPLOYEE#; b-L( 3 DATE: d Z7 L <br /> Date Service Completed (if already completed): SERVICE CODE: S Z� P/E: 6 Q <br /> Fee Amount: -241Amount Paid 'j4f, -;1-&-7 Cri) Payment Date I';,, � / / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6"5-02 <br />