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SAN JOAC J COUNTY ENVIRONMENTAL HEALT_ )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � ,v / <br /> OWNER/OPERATOR <br /> C.7e_ <br /> • S Z / CHECK If BILLING ADDRES <br /> FACILITY NAME /,7r JC. /' �a("�'�4� G 06" GAS 6 <br /> � /�jC/7!�J � L <br /> SITE ADDRESS /D ow 5 /� Ti• v�r%5/ <11 , STOG�'i'G�J ys ZU S <br /> Street Number Direction � f r� St�ket Name U V D. CityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) —3 1�•flecll <br /> Street Number Street Name <br /> CITY O� STATE ZIP _ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2,9 7 5 <br /> PHONE#2ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Af��j / i CHECK if BILLING ADDRESS El <br /> BUSINESS NAME /�� �J/� /'��' PHONE# ExT• <br /> (f_ ins <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �/)/� ) C/9 <br /> . STATE /' ZIP <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 /> also certify that I have prepared this application and that the R be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards E an EDERAL I WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ (f OPERATOR/ GER THER AUTHORIZED AGENT 12 ,9 f/f!v1,4 <br /> If APPLICANT IS not t $IE t/tVG 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 provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S Z� NPA ,EN <br /> COMMENTS: PErFIVED <br /> MAR 0 2 2GIS <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ?,,f 7— <br /> v <br /> ASSIGNED TO: lzi Vg„ia EMPLOYEE#: DATE: N2,/I�v <br /> Date Service Completed-6f already completed): SERVICE CODE: J! t,0'7- P I E 2 <br /> Fee Amount: lO Amount Paid 3 C7 d C.) Payment Date 3 J <br /> � b <br /> Payment Type G(� Invoice# Check# i 362/a, Received By:T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />