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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS abl---dQ Gy �S3�od <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Gr7 q.-1 _ G.T• <br /> Street Number Street Name <br /> CITY I17i�I1��� STATEZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> mss) sc►. ss-S <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR L►IPC7V N/10KV�4=IE <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEG �, '{ —F %e a `�� PHONE# EXT' <br /> 510W 1. -70ss <br /> HOME or MAILING ADDRESSFAx# <br /> ri?iM`1 1p1$¢p5a- G'T. Mae) Sa6!. -795ePIS <br /> CITY vV Or"L-1 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 <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,STATE and F L laws. <br /> APPLICANT'S SIGNATURE: DATEE:�/ I ZZ/'-X'7'/t O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ R AUTHORIZED AGENT Lam'! <br /> If APPLICANT is n he 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 <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: <br /> COMMENTS: <br /> R-+�P�,ac�+.�►eu-r oP �I..E�c +ase. ®Ec 2 �; 2010 <br /> Pia>tj0ii' 4�► PF1SX30�MXM3�-�-1v - - - SANdOAGlU1N000N"i`( <br /> H��N OUEPAR MENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: r _ EMPLOYEE M 26 C DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE: $ P 1 E: 30-8 <br /> Fee Amount: 3 �• Amount Paid *7 b -- Payment Date �� 2— <br /> Payment <br /> Payment Type Invoice# Check# s b Received By: �T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />