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bAN JOAQUIN U,UUNA Y ISNYIRIONMEI'N'I'AL MAL'IH I/EPAKI-MLIN 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �,�cc�yz yi <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS® <br /> t1t-/lrELPf + JA✓"tES l�,J�LLE <br /> FACILITY NAME L h V EL-t-E PP-o PEfzT�( <br /> SITE ADDRESS '32 T-L k S• 1z-o s-rF- - �• � E�C�Ity ,4 <br /> 9 S304 <br /> Street Number Direction Street Name Zip CmIe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4-qC. W , 1�LEW E'l`}- <br /> G/V Ciw - NfWAfz(zA StreeNumber Street Name <br /> CITY TiZ00�L� STATE GA ZIP Cy 5-3c)4 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> lZo�jl s3(o- 0005 ZSS - IcsD -2(c pA - tlooZ3y- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR nc38y J2#tGOC <br /> 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> LICE o+�� CstC�ENVIKUrJ 11'ttNTv°[L .Lpq 3ldl-o3'�S- <br /> HOME or MAILING ADDRESS FAX# <br /> 03�fq <br /> CITY �p�1 STATE C_j,, ZIP 95240 <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 <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: )of DATE: t- 1 a Z <br /> PROPERTY/BUSINESS OWNERO OPERATOR/'MANAGER ❑ OTHER AUTHORIZED AGENT® CONSVLTi_,NJT <br /> PAPPL/CANT is not the BILLING 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 enviroomental/site assessment <br /> information to the SAN JoAQutN 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 REQUESTED: 112-E.1I(EVJ $OI L S V i7r)13) L 1T-4 <br /> COMMENTS: H .11 \ k-2-- PAYMENT <br /> , 44 2A Y� a ��� RECEIVED <br /> ` 1 ((yo JAN 2 6 2012 <br /> l_ SAN IOAWN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: _ EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: ! EMPLOYEEM O DATE: <br /> Date Service Completed ( already compk+ i! SERVICE CODE: Z-� PIE: u <br /> Fee Amount: o Cl- Amount Paid 2,L-j i Payment Date -zP t 7- <br /> Payment <br /> Payment Type invoice# Check# 17j5Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11(1712003 <br />