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� 1 111 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S � <br /> I OWNER l OPERATOR <br /> CHECK If PILLING ADDRESS <br /> rT W/V <br /> FACum NAME <br /> SITE ADDRESS <br /> =S2n <br /> n! PeIr�«N �o.4n �..n�acnl gSL34- <br /> Direction Street Name Ci 2i Cade <br /> HOMtE Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> Clmr STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION Ij <br /> {?A°#) �Fsz.-4�(!S� 2Z-0- o/ PA- <br /> EXT. BOSDISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if PILLING_ADDRESS <br /> a BUSINESS NAME!"'► T—G I PHONE Exr. III <br /> t HOME Or MAILING ADDRESS FAX# <br /> P-0- gor- 2100 (201) 33%4-07Z 3 <br /> CITY pC] STATE cA ZIP 9SZ4( <br /> } BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> 1 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: /'0-Z6 —0(p <br /> PROPERTY I BUSINESS OWNER 13OPERATOR/MANAGER 11THER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO'RELEASE INFORNIATION:'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 attthe Same time it is <br /> provided to me or my representative. "1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: (�(}y n ✓� ( �9 <br /> aG � Mcr�[ `rGr� rl,�,.r uz g ycpU�� <br /> �o> fie_ 7, t. sA tAj° 0� 4eta MEcsf <br /> i' <br /> ACCEPTED BY: EMPLOYEE#: DATE: r ^� <br /> ASSIGNED TO: jEMPLOYEE#: 7 DATE: <br /> k <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ZL <br /> P4- <br /> Fee Amount: Amount Paid O D Payment Date 10 12-1 Q 6 <br /> i <br /> Payment Type Invoice# Check# �� Received By: 2� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />