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Nano, --.0K <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> >ACt�tt'b tido t� /f.1- OvSQ sratr .�.� SQ COE,zt*1 f <br /> vtTb T'> TCkM��IJ. <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS E] <br /> �w✓soct-o INwsr CID Gp• b -lc, <br /> FAaurr NAME <br /> 5£�17-0 5' ISO <br /> SITE ADDRESSS- <br /> 13St 1S 1}iGNtvOc1:1 <br /> Street Number Direction I Street Name city Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CI 100 (ZAD6%9- 0Ott PkItiK-WA�4 Street Number Street Name <br /> CITY STATE ZIP 6 <br /> PHONEM ExT' APN• LAND USE APPLICATION# <br /> I—AD) 626 —GZz <br /> PHONER EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR IIS�II <br /> REQUESTOR CHECKIf BILLING ADDRESS�L�J <br /> NkA b t�FiiLl FaCL S�t�.O <br /> USIN SS N ME PHONE# <br /> bl 2250—9 30Z) <br /> HOME or MAILING ADDRESS FAX# S — CI,333 <br /> 267405 sggao CA-0'J ot-) �. �� C3 '' (6 l) -Z O <br /> CITY •O C6VN,.rr..A STATE vA,- ZIP G I'TL I <br /> BILLING ACKNOWLEDGEM``E_NJJT: 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 ork to be performed will be done in accordance with all Sax JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F aws. <br /> APPLICANT'S SIGNATURE: DATE:: <br /> PROPERTY/BUSINESS OWNER❑ /MANAGER ❑ OTHER AUTHORIZED AGENT ( <br /> If APPLlciNT'isnottheB1LDNGPAR 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. l <br /> TYPE OF SERVICE REQUESTED: (�(_$'•7— .p�N G S%�4.t-C-.4'iT p,v P <br /> IVED <br /> CoMNENrs: <br /> FEB 222012 <br /> `'r' UIN COUNTY <br /> NXRONIAOUAL <br /> Ni!!AL r1 DEPAR'r11EM <br /> ACCEPTED BY: (v EMPLOYEE tJ DATE 1 f Z <br /> ASSIGNED TO: GAC-v" T'T- EMPLOYEE#: /422-- DATE: 7-74(2-- <br /> Date <br /> 7I IL <br /> Date Service Completed (if already completed): SERVICE CODE: 0' i PIE: Z3C3 <br /> Fee Amount: 4 (Oo o, Amount Paid 11 b o i) a i7 Payment Date 2 y 2- 12� <br /> Payment Type Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />