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JA.N J0Al1U1N 4-0UN'l'Y ZN V lH0N MLt'N'1'AL 11EAL'1 H LEPARI'MEN'I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o b7� <br /> OWNER/OPERATOR -PJA <br /> �IJ1 <br /> fCN JPCt;j-(LONINGtfJ CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> 1I t°�N GR-O NINVEN PROPt=R--C�f <br /> SITE ADDRESSISIOD- S- SPC -LONE ftn. ,MhN�2=C.IN Of T's y <br /> I � �—Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SP%YVIC Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 201) q92--5-z4fr 203- O(QO - (3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �t4By R-tKCU CHECK UBILLING ADDRESS <br /> BUSINESS NAME PHONE# ET. <br /> trtV e CA1L C toE0.lv125r yKF-nfTfAL- yoq 3(dr- O33"S <br /> HOME Or MAILING ADDRESS4p-+ VJ, OAK- $'T. ( Zo-t) 310-)-03�'} <br /> CITY L-0-0 i STATE C e, 7jp qV)1 0 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 JOAQuTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 Z--'} <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® CO/jSvL'rY1>✓T <br /> ifAPPLlCANT is not the B/LLt,vGPARTY.proof of authorization to sign is required Tfrte <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 enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENv(RoNMENTAL 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 REQUESTED: l2e4IEw SVP-FACE + S035VP-Fdk� C,p�A'W1irJA-n Otv IL-EPoILT AYME <br /> COMMENTS:/ 3 . . DEC 0 7 <br /> 20C12 <br /> SA ENVRQUTAi111+1o, yLrwj 6b MW /DAcou <br /> HEALT11 CP <br /> � <br /> TME <br /> ACCEPTED BY: EMPLOYEE M DATE: 4:;2 LV42 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: fly? <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 D, I ' �'d 6� k/y1J� �O ��t�� GSXlSR FORM(Golden Rod) <br /> REVISED 11/17/2003 V <br />