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s <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR FACILITY NAME ' q <br /> �''�'� r5 Q CHECK If BILLING ADDRESS D <br /> LL �'r' ��� <br /> f'lrl"� <br /> SITE ADDRESS <br /> �7 76Lr icz - o AcarlK 9sz-z.a <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) N C.14r4r-4 <br /> 162to Street Number Street Name <br /> �. CITY STATE ZIP <br /> 5 fioc Ft-TbH A ?I-Z b q <br /> PHONE#t EzT• APN# LAND USE APPLICATION# <br /> r [ ) 01PA - 1-tD 0 Z�c7 <br /> PHONE#2 Ext. BOO DISTRICT LOCA WE <br /> [ ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTbR CHECK if BILLING ADDRESS 11 <br /> - T11tFDI2 a <br /> BUSINESS NAME PHONE# ' <br /> G71;b_fWV5E firthTZ- 4WfNII-AL lHC. 409 6-L93 <br /> HOME or MAILING ADDRESS FAX# <br /> 7 V r4 ,-4 Ave JSQ'rre: 8- 2,40. (Zoll ) 5 61?- 0 29<�- <br /> l CITY STATE G A ZIP 9'r ,3 5 <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 ENVIRONNENTAL 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,S and FEDERAL laws. <br /> LICANT'S SIGNATURE: A/T� (1/1 /Za)3 <br /> /PROPERTY/BUSINESS OWNER❑ O ERATOR/.MANAGER ❑ OTHFRAUTHORIZEDAGENT (y L <br /> r <br /> IfAPPLICANT is not the BILLING PARTY,proof of 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 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 /> �. <br /> TYPE OF SERVICE REQUESTED: LJ <br /> COMMENTS: �'MAY 3 z 2013 <br /> 'N JO RQUl�COUN7y <br /> HEALrtl UE An A- <br /> C/ 37�'W, <br /> a <br /> ACCEPTED BY: t EMPLOYEE M DATE: 3L <br /> ASSIGNED TO: I• i G EMPLOYEE#: s DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: <br /> p'� <br /> Fee Amount: Z�.(� Amount Paid-l&�6 6Payment Date '5/3//I3 <br /> Payment Type V Invoice# Check# ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />