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SAN JOAQUI'- �OIJNTY ENVIRONDIENTAL HEALT'v Y)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5. <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS -�- SL-14 I Q _\ 1.\ G ���\ �S G \�a� <br /> lO <br /> Street Number Direction �f Street Name i qZi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (tel `$33 - o 3S Z(Z - os o G 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `, <br /> I�\ CHECK If BILLING ADDRESS <br /> BUSINESS NAME V f\ _ (1 �O PHONE# _ EXT' <br /> 3/2HOME Or MAILING ADDRESS <br /> 0 ^ / �^Il (V-m S <br /> CITY ` 1V \ STATE /A <br /> ZIP 1�5CT3(((a <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 or <br /> 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, STATEand FE -RAL laws. <br /> APPLICANT'S SIGNATURE: / DATT�EE�:yy <br /> PROPERTY/BUSINESS OWNER❑ DPE TOR/MANAG R ❑ OTHER AUTHORIZED AGENTTL^J \)2S•C,YlQ,� <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. REG g 1,l�6--Ft F-CC <br /> TYPE OF SERVICE REQUESTED: �-, `\c--5+-e-r - IV�'�-. �� p.�'v� �Jp o.P64�- <br /> COMMENTS: v (7 f -,f�Ifr\) L4J <br /> SAV <br /> H471 0 <br /> SC l A'ME O <br /> / VNiy <br /> �� qq EP,gR�l1E`ryT <br /> ACCEPTED BY: 0`-4 \J E( l=rt EMPLOYEE#: ®3Z f DATE: 2_ f 3 6 0 <br /> ASSIGNED TO: U-1Z-7 S C-0 EMPLOYEE M D l(-&7 DATE. 21 f 9� D <br /> Date Service Completed (if already completed): SERVICE CODE:/ S-2_2- PIE: 3( <br /> Fee Amount: ,2(() .U'7 Amount Paid 2-( 0 Payment Date 2 1 <br /> Payment Type Invoice# Check# Z $ b t"C Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />