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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> lZ'� ��,<J •: 6 009105 <br /> OWNER/OPE OR ///��� <br /> ' � CHECK If 81LLING ADDRESS <br /> FAcalrr NAME Sion'i,i <br /> SITE ADDRESS !' 770 <br /> Street Number I Direction Street Name city Zip Cod. <br /> HOME or MAILING ADDRESS (If Different from Site Address) -2z7/ .2 CGL Cm Nr% <br /> StreeJt Number Street ame <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RECUESTOR G� �/G`7/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME �rtz.2 PHONE# C ExT' <br /> HOME Or MAILING ADDRESS �6X 0�7v FAX# <br /> CITY Sylil�7Ln STATE / �7 ZIP q z/moi <br /> Lam/ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that 1 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 FEDERAL laws. l <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUsrNESs OWNER❑ OP RA /MANAGER ❑ OTHER AUTHORIZED AGEN1� �o/1%/.c <br /> lfAPPLICANT is n ILLING PARTY proof of authorization t0 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: �n Z/eQ <br /> COMMENTS: <br /> savJOA 14X20 <br /> H[q� <br /> Z/1 fP, lEjv gi IY <br /> ACCEPTED BY: fTvL LS LT7 EMPLOYEE#: DATE: P L)!(— —>� <br /> ASSIGNED TO: { { EMPLOYEE M DATE: , i _ <br /> o - <br /> Date Service Completed (if already completed): SERVICE CODE: S Z PIE: (00 <br /> Fee Amount: Q �' r &:;6 Amount Paid O Payment Date 11Z4 �2o-w <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />