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SAN JOAQ OCOUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lntz(2, 4�D s� 0 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> %ou-�eez- <br /> FACILITY NAME <br /> SITE ADDRESS 1{t„ya 88 v vl VE-. �{wy BCS LQ-Ir..��U1�O <br /> X40 Street 14ambar Direction I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ZE3« cte-6r„J 'r— Street Number Str..t Name <br /> CIN TATE ZIP <br /> LA-) S'fWCti- <br /> 9e� / <br /> C <br /> PHONE#1 `l Em APN# LAND USE APPLICATION# <br /> 6% g?C) 3`�gC7 <br /> PHONE#2 EM. BQS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Gc�a N� u1�t ek <br /> BUSINESSNAME T�/ t PHONE# EM' <br /> �y tie het J«x �m 9/C 87c Mgp <br /> HOME Or MAILING ADDRESS FAX# <br /> 2'51-7 3722- —qS716 <br /> CITY S *c✓"?M O" STATEC'a ZIP CD'6-01 <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 FEDERAL laws. /^ a <br /> APPLICANT'S SIGNATURE: ( /�— �� DATE.. A:{ b p C7J} 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C(d Lo(�- 0�3' <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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. T <br /> TYPE OF SERVICE REQUESTED: ECE1VEo <br /> COMMENTS: 3U14 <br /> q [ 2 <br /> O 8 <br /> SAN JOAQUIN COUNTY <br /> 14EN,fHDEPARTM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: L DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: <br /> Fee Amount: #- Amount Paid 'a(I}i, Da Payment Date I,p 2 S Q -Z <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />