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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�Lr�� w 2at &Toust <br /> OWNER/OPERATOR <br /> 6r14�1 �� � T 9M& F CHECK If BILLING ADDRESS <br /> FACIDTY NAME�jJ A 1 Fxp,,V6� r'A <br /> SITE ADDRESS tom- C � WoOP-AJ 1-as) NAw7Et/5, �•53�'� <br /> 4(/4 Cs Street Number I Direction I Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Eur. APN# LAW USE APPLICATION# <br /> (coy) & 31 —"10E 'or-Dc) <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V/1�3; <br /> v/'tY�w J Iv1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME \ f PHONE* Exr. <br /> V z 31 - 5410 <br /> HOME or MAILING ADDRESS FAX# EIvW)(, , <br /> o f C-ofR-D ( ) GVIEtIZAZ@P� t4 E,net <br /> CITY 0A <br /> 10 bSS�� STATE GA_ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned properly 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.SrATE and FEDERAL laws' <br /> ` ' )—Cl <br /> APPLICANT'S SIGNATURE: I '\ • `� � DATE: 0 Z I <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (JN> <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS prOVlded to me or <br /> my representative. yn�nA ^ ,D J RECEIVEDYMENT <br /> TYPE OF SERVICE REQUESTED: F- V I S 1.d N (,fOIA <br /> COMMENTS: ,�/.��// MAR 21 217 <br /> ,� L 1�' // tq�"n) b`lh'` r^C �phl JOAQUIN C NTY, <br /> eo Dv/'` ENVIRONMEN AL <br /> 1 "HEALTH DEPART AENT. <br /> ACCEPTED BY: Arlada EMPLOYEE#: DATE: �I <br /> ASSIGNED TO: w10 EMPLOYEE#: DATE: �,► <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> ' 52 <br /> PIE: <br /> Fee Amount: Amount Paid Payment Date a 21 <br /> Payment Type Invoice# Check# By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />