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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t <br /> SERVICE REQUEST <br /> Type o€Business or Property FACILITY ID# S VECE REQUEST# <br /> OWNER/OPERATOR / /��Q /� <br /> 6G. l L r/7-0 FNV IL y UiAZ Y06,5 CH cK' L N o ESS <br /> FACILITY NAME <br /> SITE ADDRESS/z r S 5 5T. PT q 9 fes. F,eauMCrC MI. ^R <br /> Street Number Ir ton Stree me �N76` ����v <br /> HOME Or MAILING ADDRESS (If Different from Silo Address) as <br />'r Strcal Numher 5 et N e <br /> Ih CITY STATE <br /> ZIP <br /> PHONE#1 EKT APN# LAND USE APPLICATION# <br /> 097) SZq-3677- <br /> PHONE#2 EXT. <br /> i SOS DISTRICT LOCATIQN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR yl <br /> REQUESTOR r7 <br /> 1k71C 11WZ <br /> ,Q CHECK if BILLING ADp1sE�M <br /> BuslNess NAME ��GIC1 r 1-+ PNDNE# �xr. hi <br /> (� 2 <br /> 8 3G�� <br /> NOME Or MAILING ADDRESS <br /> 2a o 1 S A1 <br /> S . � q FAX# <br /> CtT„ <br /> NlA4v7-'SCA STATE�A LP <br /> BILLING ACKNOWLEDGEMENT: T, the undersigned property or business owner, operator or authorized agent of same, to <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 application and that the work to be performed will be done in accordance with all SAN JoAQUiN <br /> COUNTY Ordinance Codes,Standards,STATE FED llalws. <br /> APPLICANT'S SIGNATURE: (�/ DATE• f/ Q <br /> PROPERTY/$UStN1;SS OWNER D PERATOR/MANAGER E3IZ <br /> OTHER AUTHORED AGENTO <br /> IfAPPLICANT is not the BILLINGPARTy proof of authorization to sign is required Title <br /> AU11-M zATION 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 envirorunentaUsite 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: L-L t <br /> COMMENTS: <br /> V ( F� C-0 n!N G{Z OA--) ��3 �£L 0 CA� 7� o-FIGc c�,YMENT <br /> -S:-.7 rZ <br /> c <br /> )JN <br /> t <br /> EIVE�? D <br /> PW <br /> AccEPr=n Br: L-C V 1+D—+. EMPLOYEE#: DATE. <br /> ASSIGNED TO: MPLOYEE4 S t O E #: <br /> T <br /> i f <br /> [S <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Foe Amount: f D S -�D Amount P � <br /> aid '1)S. Payment Date <br /> [ { <br /> Payment Type Invoice# Chock# Received y; <br /> EHD 48.02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) t <br />