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' SAN JOAQUWOUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE EQUEST# <br /> Per nq ne n+ Cosine fl c, S4 <br /> -CQ&2L� <br /> OWNER/OPERATOR —/ <br /> (��a171 Wa SOlt CHECK If BILLING ADDRESS O <br /> FACILITY NAME C`?017n G7 O ll B✓O� S-1-1651411) <br /> �u OI/� /0-S � s 0/0/7 TSITE ADDRESS /O'G 'I S ?�✓e. s�v (��! 9��Q <br /> Street Number Direction aName city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P.D' s o X G 9y Street Number Street Name <br /> CITYS fUG� � $21- ZIP 9S-Z/ C1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# / t� <br /> WO V9102 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C hen n so✓1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME C'�IArirlda15 gtoo S1Ilfdlo (20q EXT . <br /> Z1�O <br /> HOME or MAILING ADDRESS FAX# <br /> 1p, D, 304 00-3'111 <br /> ( ) <br /> CITY S&ly--kj*)n STATEC41- ZIP 9s-Z& <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � �2_�(�� DATE: '/L S O <br /> PROPERTY/BUSINESS OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen I/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at )iw,time it is <br /> provided to me or my representative. /V <br /> TYPE OF SERVICE REQUESTED: Cw n Su I t Q+i u 1 �Q <br /> COMMENTS: �O t � , <br /> NV�,4Q1Jt 8?�2O <br /> h�CrN0'6"R M rY <br /> Nr <br /> ACCEPTED BY: Mil U Q EMPLOYEE M $ I DATE: <br /> ASSIGNED TO: RW O Gf I(On EMPLOYEE#: DATE: r� <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 P/E: V I 103 <br /> Fee Amount: -V (S2 ! Amount Paid /���� d� Payment Date 2r <br /> Payment Type Invoice# Check# It 21_3 Zq� Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />