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..-� I.-* <br /> SAN JOAQUIN COUNTY ENVIRc.- )t,1TAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 20 �I z�5 <br /> OWNER/OPERATOR <br /> q- I T G I L CHECK# ADORES <br /> ADD <br /> 1-�FAcLnY NAME 6//��� /�r <br /> StTEADDRESS 2-Z,350 IVA'VA't" :)LJtr Z'1 AJ oed <br /> Street Number Direction Street Name city Zip Code <br /> HOME Of MAILING ADDRESS (If Different from Site Address) V(2`NE Anc 91tt vE <br /> Street Number Street Name <br /> CITY ,�.� f STATE C-.^ ZIP 952-0-7 5 ` <br /> 22-0^ <br /> PHONE#1 l f V&T. APN/ "NO USE C"PLICATION# <br /> � ) Ri2 -099 A - <br /> PHONE lfl EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IiUU l CC-r•1gC2 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXr <br /> HOME or MAILING ADDRESS <br /> Re 0 X ?�-e,� ZI ZU IZxct I 334--o72-3 <br /> CITY IN 01 STATE ay ZIP Lf / <br /> RMLING 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,STA and EDERAL laws. <br /> APPLICANT'S SIGNATURE: u DATE: Z ` c-f <br /> PROPERTY/BUSINESSOWNER❑ O ERATO MANAGE OTHERAUTHORIZEDAGENT� <br /> IJAPPLICANT is not the BILLING ARTY proof of authorization to sign is requireed Title <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 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 i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: .' RECEIVED <br /> COMMENTS: 1 JUN 2 4 2005 <br /> LP-3� -//7• $ANOCOUNTY <br /> ENVIRONMENTAL <br /> (.lvNe^'g,D HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 9 BS <br /> ASSIGNED TO: PLOYEE# DATE: (/ <br /> Date Service Completed (Ifalready c fed): SERVICECODE: S ZZ PIE: 2� <br /> Fee Amount: Amount Paid a Payment Date <br /> Payment Type Invoice# Check# R ceiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />