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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property LFACILITY ID# SERVICE REQUEST# <br /> R le G L /LESiD, /&l714L <br /> OWNER/OPERATOR ,t <br /> M,e L EDO DEL try kopg 16 uECHECK If BILLING ADDRESS <br /> FACILIry NAME <br /> SITE ADDRESS w f1NC�N4 �a /SOD <br /> SS Street Number Direction Street/NName city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 0 <f` 'c2,`. Street Number Street Name <br /> CITY ft^ L7— STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# / . <br /> O -C7 NoTRVi-1/G�SCE J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PO,J CHECK If BILLING ADDRESS <br /> C�/�5/v� <br /> BUSINESS NAMEPHONE# E.T. <br /> CffESn/� G'a�l5l,« T/�C ( 6G8-/¢o <br /> HOME or MAILING ADDRESS FAx# <br /> o 00x ( ) lots -'2 <br /> CITYf L Q STATE ZIP S <br /> 30 <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 appfi tion and that e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STT and FE S. <br /> APPLICANT'S SIGNATURE: yt DATE: 3 -19-42:3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR//MANAGER ❑ THER AUTHORIZED AGENT er <br /> /fAPPLICANT is not the BILLING PARTY proof of autl oriZation 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 /> TYPE OF SERVICE REQUESTED: SL(RFAGS A[ U u CO/llT M/ OtII EP E a✓ <br /> COMMENTS: - - <br /> 1 RECEIVE <br /> MAR 18 2004 <br /> (�G SAN JOAOUIN COUNTY <br /> C <br /> ENVIRONMENTALARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: —I <br /> 4 <br /> ASSIGNED TO: EMPLOYE - �[�. DATE: <br /> Date Service Complet d (if already ompleted): SERVICE CODS C> P 1 E: 3 <br /> Fee Amount: O Amount Paid 9 8�6 tTI') =Payment Date 3 ( O . <br /> Payment Type Invoice# Check# 'S78' Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />