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SAN JOAQUIN ^ OUNTY ENVMONMENTAL HEALTI'nEPARTMENT <br /> 1' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pv'i vo,4c ady� S ICv U 3 ci /U <br /> OWNER I OPERATOR <br /> `;'�N CHECK If BILLING ADDRESS <br /> S <br /> FAcnm NAME f A��GH�� 1..•(!t, J 77/r -y.( <br /> SITE ADDRESS <br /> U Street Number fon t tr Name Ci ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Streak Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND US LICATION# <br /> (wy ) 931- 6/0l 0 "- 0J0 -i? M o a -36 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> (7a ) ( -S027 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR /�� ! e"L I/1,� u CHECK if BILLING ADDRESS <br /> BUSINESS NAMED( c �4 ry�� PHONE <br /> � <br /> U Y l�C +-1 2.61 <br /> McMEOrMAILINGADDRESS FAX# <br /> CRY C jk fo" STATE 614 ZIP S I <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and FERE la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ]PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT is not the BILLING PARTY,proo 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 environmentallsite 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. NT <br /> TYPE OF SERVICE REQUESTED: AJ 177 <br /> COMMENTS: <br /> Jr9/ 2&5?-,rA-7'Peut>Z'62) '00-6n k?a)16+t�D <br /> SAN d�pNOk'E TM Nt <br /> �16 mile <br /> ACCEPTED BY: r) I-t U F Ie-,d, EMPLOYEE M 032_1 DATE: Z /I O <br /> ASSIGNED TO: l_ m <br /> ISC 0o EMPLOYEE 5-Ct 4L/ DATE: /-- If <br /> ft o <br /> Date Service Completed (if already completed): SERVICE CODE: 5 25 PIE: L b.Fi 2 <br /> Fee Amount: c f(o$' oto Amount Paid if,tl. 0 Payment Date 0-t <br /> Payment Type ✓ Invoice# Check# Received By: 2,C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />