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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EA 00SL4 531 <br /> OWNER I OPERATOR <br /> 1i1 �a G L4� �y- 2 CHECK If BILLING ADDRESS <br /> FACILITY NAME G,A c n i u o f w evo <br /> SITE ADDRESS (PA S � IIC'-T'! "'\ Sa-o�t.I-J� Gj�i215 <br /> Scree!Number Direction Street Name 'I CIf ZI Cotle <br /> HOME Or MAILING ADDRESS (If Diifferent from Site <br /> �A)ddre'yJ [� <br /> Nl 3t . Street Number Street Name <br /> CITY + STATE ZIP a S <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (dog) <br /> PHONE#Z Exr. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> (I ie ` ,` !.A /t J1 o n � t p�r t��2 - CHECK if BILLING ADDRESS <br /> BUSINESS NAME /F•�,(,f�v�`I �I '��tt�V�� l� J��LA to �� PHONE# '54(0 a Exr. <br /> HOME or MAILING ADDRESS ii, '/et--ll (AX# ) W L� <br /> `lhJ sJ 1 <br /> CITY Is <br /> to <br /> t (-yah A STATE tT zip q rs 105 <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 Coder,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (JL Y1 G M pH If- <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLicANT is not the BLLLLNGPARTP 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: T V O t/17v 1�LI'� o1Yp6 7 <br /> COMMENTS: <br /> VYlU1Y1„1/tYQ' ,ly Wy��� 'C '220 <br /> H � �pAN� <br /> ACCEPTED BY: \r. imwtQ1 EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: v <br /> ZFeeDate Service Completed (if already completed): SERVICE CODE: (� PIE: IQ 02— <br /> Fee <br /> Amount: 1S2 i Amount Pal /�a�0-6 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />