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r 0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (50 11 Was{7✓ Slaw(0 3 9 q q- <br /> OWNER/OPERATOR 1\A„/G,t,t0 f R� �� l <br /> rj CHECK If BILLING ADDRESS <br /> FACILITY NAME I� i0�I�/ �•y,���" 1 ��-S ,'n p <br /> SITE ADDRESS (v` �GL�1'!ftJ11 �� (so-'+� <br /> Street Number Direction Street Name og 1 Ci Zip Code <br /> HOME or MAILING ADDRESS If Different from Site Address) <br /> oV�1dhiq �l Street Number Street Name <br /> CITY Av- " ! y V I� o—A STATE � ZIP t D <br /> PHONE#I E'R APN# 1-75-17c)—IF,-11 LAND USE APPLICATION# (� <br /> ( F/7) Li 15 G3 57 17S-- 00 O 1 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> � <br /> ` CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR "/ J <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME J,/Ks PHONE# & � EXT <br /> HOME or MAILING ADDRESS tr/ <br /> 2F7o G 2 dakS O� tS14Fk 150 FAX <br /> lib ) fn7� Zgoo <br /> CITY STATE ZIP Q3 <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 FED RAL laws. /n <br /> APPLICANT'S SIGNATURE: 06", Y+1'J �y l DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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. -j- <br /> TYPE OF SERVICE REQUESTED: L�- t/'�� 1+` �+ ��---� � F'A IV O <br /> COMMENTS: 1;214? // — ���C�Y 1s�ii ;Y� r!1/ f _ 1 1. <br /> 411 <br /> r a/6he p Y;-4 V—2 7' DEC <br /> r2`�. SAN.IUAQl'N AL <br /> �.//�S'sw/i.,te: ,,y'u.l�..-;77 � /•elro 4,•1� lu-l�*int�.,,r-i"Z,�.y ,�-.'t�,,,l t;s��S 7.�•v�->'.e� • ENV1FiDEP �ENt <br /> ACCEPTED BY: � , ' EMPLOYEE#: A?,(".4 J DATE: <br /> ASSIGNED TO: Vie'.�, � y ,� EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: W40 7 <br /> Fee Amount: 377® Amount Paid 193-7S D tI Payment Date 1Z <br /> Payment Type �1L Invoice# Check# Receive By: <br /> EHD 48-02-025 Ti `" SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V <br />