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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F/- Oct <br /> OWNER/OPERATOR <br /> � <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME —G+ � <br /> SITE ADDRESS G7 <br /> b cn <br /> Street Number Do-eou �D �'� F'� .H S te_/div Zip del U <br /> Hama <br /> HOME Or MAILING ADDRESS (If Different from Site Addre s <br /> 6G O ze"fe /(-L,eftm.$gylL 53 Street Number Street Name <br /> CITY STATE ZIP <br /> S1�c 1Gr�N A Q1-2-1 <br /> 0 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (1-10q)) - zz a 7q) 70V6 <br /> PHONE#2 EXT. BQS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /- CHECK if BILLING ADDRESS <br /> BUSINESS NAME > lJ, PHONE# / EV <br /> SrYrrl m S T t/r•J 'r-/'F O Zo;Z <br /> HOME or MAILING ADDRESS / FAX# <br /> / ( ) <br /> CITYL /< N STAB ZIP 'f7 r Z ) it <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . Kr- DATE: ZZ/'r- <br /> PROPERTY/BUSINESS OWNER OPERATOR OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 13If APPLICANT iS 110t 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERW REQUESTED: o " Flgn E <br /> ED <br /> ECEIVEC�' hanqed bm { Lev) lm� coli LV ' l fv rte 3 2011 <br /> EB nuwc.UN,POA r 14 n. ' OLeGk �� ,f 15 26V � cpha/We- 11 111 l pEp"#"Oqc ry <br /> s <br /> H XiAi EMPLOYEE#: DATE: - !/ _/ <br /> ASSIGNED TO: "11rZ EEMPLOYEE#: DATE: a ./ _/7 <br /> Date Service Completed (if already Completed): SERVICE CGDE: - PIE: <br /> Fee Amount: �F Amount Paid Payment Date <br /> Payment Type Invoice# Check It Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> S <br />