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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CG6ISCLI, <br />FACILITY ID # <br />---,o9-4 -- po S <br />SERVICE REQUEST # <br />OWNER / BPefetT6R <br />�Cr%7}lj�:I�//✓ CQ�� 6// / ! ��C�� G�C//� Ie� �G i / �'(f CHv BILLING A��ESS <br />F✓ <br />FACILITY NAME <br />SITE ADDRESS //3Q <br />Street Number <br />��i� <br />Direction <br />� /� - 1*ZGU-x./ kD <br />Street Name <br />1,11FAC <br />City <br />/ 5'3 77 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) e/o�ZLt► <br />Street Number <br />e �(f /t/ j/� <br />Street Name <br />„ d ZIP Q S a® S <br />CITY �.-.. / STATE el* <br />i/ 7 <br />PHONE #i EXT. <br />APN # <br />LAND USE APPLIIC7ATION # <br />PHONE #Z EXT. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR i , <br />REQUESTOR Com' -CG cl�lt, /�,�P� L L <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEe..iU21,D <br />PHONE #0..9 <br />o <br />g� <br />0 <br />G6 —7 a is <br />N6MEllr MAILING ADDRESS�” g,- ® S , f-�r / �i / <br />"/s / D <br />( ny) <br />f b/'p '" 30 7 <br />CITY ��70?L-1STATE <br />4:54 <br />ZIP <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 FE RAL laws. <br />APPLICANT'S SIGNATURE: Ir DATE: �0{7� _ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ,SE �VJ `+ <br />If APPLICANT is not the BILLING PARTY, proof of authoriZatdon 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: ,�p/�Q^®I�G I�- /l /�RI���-,,'/,�•e/!e //F%S^�a�/!� L L //�y <br />®/�,/�rw <br />�/ <br />ACCEPTED BY: 9ryP — <br />EMPLOYEE#:DATE: <br />Y/ -� <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />1-'1910-7 <br />Date Service Completed (if already completed):/// '//,97 <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />