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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 74 <br /> OWNER/OPERATOR <br /> 5AU SOF Gl4 YTO RSC�'mrJk! 1"0'ormS 17'r- CHECK If BILLING ADDRESS <br /> FACILITYNAMES S 2 SD ml/r�wrT'�^r.Jp►1L F'FLy/..}Ty <br /> SITE ADDRE;S5,33 �� LSlJbX'*r 50f 54- $10 9$'205 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME lN' PHONE# EXT' <br /> leaGt£y 367-480o <br /> HOME or MAILING ADDRESS FAx# <br /> 2,S-76 m&(CwD 415W&L-S- (2oq) 36-7 - S4-24 <br /> CITY L-'O C S STATE .� ZIP qS Z,+O <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 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. <br /> APPLICANT'S SIGNATURE: - �- DATES:,/ <br /> PROPERTY/BUSINESS OWNER❑ OPER OR/MANAGER 13 OTHER AUTHORIZED AGENT IYI CO S X It-ro <br /> IfAPPLICA,NT 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. <br /> TYPE OF SERVICE REQUESTED: R ftne.FLD A✓I) fLVJ1AV-Vb ILOCA� I Sf�)$dR- 60"-4b%=C*A <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> FEB 0 2 2012 <br /> SAN JOA QUM COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: LU Lt!C EMPLOYEE#: �v5 DATE: 2—/Z- (2— <br /> ASSIGNED <br /> ZASSIGNED TO: L'�JL7 ti) EMPLOYEE#: ��CL6 L, DATE: 42—//2— <br /> Date Service Completed (if already completed): P I E: 2-3 C' <br /> Fee Amount: '7T',S CC Amount Paid '�3'�S', p Payment Date �r( �— <br /> Payment Type ✓ Invoice# Check# a-�'s Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />