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�VUL.1 X rAvixvlvnlEtNIALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cl/u2Gf/ T <br /> KO o 4 co_`j <br /> OWNER/OPERATOR <br /> RX.fmgL CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> G R/ T <br /> SITE ADDRESS 11¢73 WAST ARCH 9?5 <br /> Street Number Direction Street Name C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /�,cs PARKE.e siVa>=h�Gl <br /> Street Number Street Name <br /> CITY STATE CSF ZIP <br /> PHONE#1 (' ExT• APN# LAND USE APPLICATION# <br /> - l3B 2�2-/eo- 2S -o - // <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> `i 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> N C <br /> r CHECK If BILLING ADDRESS <br /> BUSINESS NAME E PHONE# <br /> NE EM' <br /> — o <br /> HOME or MAILING ADDRESS FAX If <br /> O . OoK ( ) 669-2599 <br /> CITY 0 STATE CA ZIP 17!5_301 <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. <br /> I also certify that I have prepared this ap 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, rE and RAL laws. <br /> APPLICANT'S SIGNATURI At& — DATE: <br /> �I <br /> PROPERTY/BUSINEss OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 14 <br /> If APPLICANT is not the BILLING PARTY proofo authorization to sign is required Title <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 environmentaUsite 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 REQUESTED:A117-trAM 449AOL&� 01,e S f U <br /> CoxRENTS: AVIC✓(rl (zomrr�/ (yv RECEIVED <br /> 2 IV <br /> SAN JOAOUIN G VAL <br /> Et.IVIFONMAR MENT <br /> ACCEPTED BY: EMPLOYEE#: 95;�// ATE: or-1,?-07 <br /> ASSIGNED TO: EMPLOYEE#: l S DATE: 2 '//L^9P�j( <br /> Date Service Completed (if already completed): SERviCF CODE: S' PIE: 2 4�_ j•' <br /> Fee Amount: yrs Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />