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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S9-005g2 (o ? <br /> OWNER/OPERATOR <br /> trc- -;--I mm t a L{C CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Los <br /> I f S 1 r <br /> SITE ADDRESS � �4C i��-"Z L S j""�L� 5Toc l ty E-5-Zo7 <br /> Street Number plrectionStreet Name Cit ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> [Lb ! i S L t% y 5stNStreet umb., �� �� S H-I ni if -or <br /> Street a e <br /> Grr 1�Tb� sTATE zip Sr Z¢7 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> { } I-J3 \ o20oi <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( I e <br /> CONTRACTOR/ SERVICE REQUESTOR �- <br /> REQUESTOR C <br /> V CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEj ��j PHONE# EXT. '�2 <br /> [_ qo 2, �� zz .J <br /> HOME O`MAluNG[ S RES F��1256F�n� AV &33 -ZI! FAx# <br /> r ('fir 3 C(y- G -ZL <br /> CITY S'roC(LTc?P�I STATEC A zip 9 s^7 7 <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 /> I also certify that I have prepared this application and that the k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL I w . <br /> APPLICANT'S SIGNATURE: DATE: ( <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MLANAGER ❑ 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, 1,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. A <br /> VA <br /> TYPE OF SERVICE REQUESTED: > 'E E 'ZIVT <br /> COMMENTS <br /> MAY Z 6 2 <br /> 008 <br /> -Pcd—K� �t1 �(�l l�"L/N 0AQUIM CO <br /> UNTY <br /> ACCEPTED BY EMPLOYEE M576 DATE: <br /> clq <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CoDE: PIE: <br /> 2� <br /> Fee Amount: Amount Paid q 6 . Pa�,DlateyCZ �Payment Type L . Invoice# Check# Sved By: <br /> EHD 48-02-025 <br /> REVISED 1111712003 SR FORM(Golden Rod) <br /> I/ <br />