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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH r.d.PARTME:NT <br /> SERVICE REQUEST <br /> Type of Bae4iesrrm Property FACILITY ID# SERVICE REQUEST# <br /> e1z�,> c�.WRfr � c •�� L 3 9—,gam — �3 �? 5 6 <br /> OW�NNE,R'/OPERATOR <br /> �/i/- �V/'7 LL•//^' C���/ll/ ! /[�(��L�C v"r/!s�� �f��� svG lK If ILLIN%DDRE <br /> FACILITY NAMEG/G L <br /> SITE ADDRESS 3 S!�O j'i/Lt�i¢ lw'J�'.2��-� 1' LC IJl✓.t'D R/lr -1 175-3-77 <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /(r/0(j ��ZC-� <br /> Street Number �i Street Name <br /> CITY St ZFZ STATE C ZIP <br /> PHONE#1 Y`/`' U/°� EXT* APN# LAND USE APPLICATION# <br /> (2v9) t6e-'3v1 4 P53 ® ?® /v <br /> PHONE#2 EXT. BOS DISTRICT7�77LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR /C� c C �� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /may/ �'�TyZ/�N�� L�N/ Y�/-p�A �GZ�N /r PHONED <br /> EXT. <br /> HefitE-er MAILING ADDRESS �s ® �^� / y ® o 09) ��V I 9 v, 7 e <br /> CITY ����� �� 6 STATE e,�J ZIP �?5%2-0 / <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 FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT //Je-lyl o �w/L G�^IYIAleYR <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 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: �RfG l I�✓S� �G/l�/�/�� / v/G �/�S��GG//v 7 /°' <br /> rule Ale <br /> ACCEPTED BY: EMPLOYEE#: DATE: ///-0/10 T <br /> ASSIGNED TO: EMPLOYEE#: ���� DATE: 1'�IFID 7 <br /> Date Service Completed (if already completed): `// SERVICE CODE: P/E: 4�40 7 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />