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SAN JOAQUI COUNTY ENVIRONMENTAL HEALT'-DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /} R1CGlLTGf/1 L RES/D /T/f(L I-�>/eCD4-3o <br /> OWNER I OPERATOR <br /> /1 . ",5EQ Qlr/4'Q CHECK If BILLING ADDRESS <br /> !` <br /> FACILITY NAME yy <br /> SITE ADDRESS 2goo WEST //9A AJeVf0 T,�Cy /S3c <br /> Street Number Direction Street Name C'tY Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3/O e "W A NCG(s0 <br /> Street Number Street Name <br /> CITY7/` ^Ft C STATE ^A ZIP fS3O* <br /> PHONE#1 /` Ems' APN# LAND USEAPPLICATION# <br /> ( ) 32/- 2279 ` X39- DSa - Z-g;- ('A - Oz -o <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DoAJ <br /> /V I C � CHECK If BILLING ADDRESS <br /> BUSINESS NAME rr J/V PHONE# '' <br /> OA(E: N Con�Iu �T/� 8- �fo3 <br /> HOME Or MAILING ADDRESS FAx# <br /> / , O • 5,9Y 3 74 ( ) 68 2s <br /> CITY U EL LO CK STATE CA <br /> ZIP gtr-�8 <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 3 <br /> I also certify that I have prepared this appy ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S75,ft and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR'/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY pro ofofa thoriZation to sign is required Tirte <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 REaLEESTED: SOic ^F1?C/OLRT1t91V I�/ POR PAYMENT <br /> COMMENTS: r0_. u GALA � 3D <br /> ry (�j� JUL 1 3 2005 <br /> S EJOAQUIN TM <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: OF// DATE: r <br /> ASSIGNED TO: Ae— EMPLOYEEM YQ4r0 DATE: 7-✓ <br /> Date Service Completed (if already completed): SERVICE CODE: $`yam• P I E: D! <br /> Fee Amount: ` Oa Amount Paid - Payment Date 3 D� <br /> Payment Type Invoice# Check# �( eceived By- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />