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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,OWNER/OPERATOR <br /> i� A r'l 1 �l r I S CHECK If BILLING ADORES <br /> )t'�4A�r.R 5� <br /> ACJ Lm NAME <br /> S* <br /> ^v 'N 1rJ < r <br /> SITE ADDRESS <br /> p s �o•�s� JI 9 242 <br /> 17 2A Street Number Direction Street Name Ci Code <br /> p,HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> TTY STATE ZIP <br /> VtL C !4�r C1 2S3 <br /> PHONE#1 EXr. APN# / LAND USE APPLICATION# <br /> (/ (20'1 ) -5,54 .05 t3 t7Z > I(, o � Z � tl Jot �i17 <br /> HONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RFgUESTOR <br /> CHECK If BILLING ADORESS <br /> ,BUSINESS NAME , ,S 1 •-• G PHONE# � 3 4 _C7`J I EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 227 ta`j N ( ) 3:5-'r- ` 611 co <br /> CITY /t e �rlP`, STATE GA ZIP 1�S Z Z 0 <br /> WILLING 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 dinanee Codes,Standards,STA d 's>a L laws. ( <br /> (CANT'S SIGNATUR� DK�e: 7 Z `t j 1�i <br /> PROPERTY/BUSINESS OWNER OPER1y+ /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLicANT is not the BlLL,wG PARTY,proof of authorization to sign is required Titre <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 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. P <br /> TYPE OF SERVICE REQUESTED: <br /> =v REC <br /> C�iFx _ F l l <br /> L) I (,wI�'/ <br /> Ul 2 4 2013ID ' rw � <br /> VwSAN , <br /> (R�µv <br /> NEAL7H OMU COUIY7Y <br /> tl �'t'lt� Wim" `� ' V rwa U[�gHrA,tElvr <br /> I' <br /> ACCEPTED BY: Frct NCI- ltf t.�Y�t EMPLOYEE#: DATE: <br /> ASSIGNED TO: IV\I LAA wLl �7 L EEMPLOYEE M DATE: -].. mat( 1 -1 <br /> Date Service Completed (if already completed): SERVICE CODE: >15 PIE: <br /> Fee Amount: l���, OJ Amount Paid.. fl 12rj 60 Payment Date _ <br /> Payment Type Invoice# Check# /pZD Received By: �< <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />