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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> y-'/11-'y"/ IiIoy q F-5/200W&2,6o <br /> OWNERI ERAT <br /> e'er-e , CtEeetHB <br /> FACILITY NAM Q aP.•d : IL .6; <br /> SITE ADDRESS/q7�umhr <br /> HOME or MAKING ADDRESS (if DNferent from Site Address) <br /> Numeer Strwt Name <br /> CITY STATE zip <br /> Plgtff#i �/_ �T APN,Y LAND USE APPLICATION# <br /> PHONE#2 - E.. uCS DISTRICT '_OCATtON CODE <br /> / I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR, C /, n ^ CHECK B BILLING ADDRESS❑ <br /> BUSINESS NAME •> r ! PFgNE# <br /> �r1 1 i7 <br /> HOME or MAILNG ADDRESS FAR III <br /> CITY STATE LP /- <br /> BILLING ACKN WLEDGEMENT: 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. <br /> APPLICANT'S SIGNATURE: ypdry -;t'& DAT777E::I' <br /> PROPERTY/BUSINESS OwNERC3 OPERATOR/MANAGER OTHERAUTHORIZED AGENT <br /> If APPLLCANTisnorthe BLU,LVGPAR proof of authorization to sign is requiredTrete <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 JoAQDiN COUNTY ENvmoNmENTAL 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 REDUESTED: �1 /L 1 ,` //7 ) S'PrJ <br /> COMMEM: REpEIV <br /> (,ZST (LF-l-9JFt1 <br /> MAR 2 12005 <br /> SAN JOAQUIN COUN <br /> .APPROVED BY: L I v&I " -SIPLOYEE 7f: 03-1/ DATE: Z.l QS <br /> ASSIGNED TO: S u 1 EMPLOYEE 111: -739V DATE: 3 2, 0S <br /> Date Service Completed (If already Completed): SERVICE CODE: t P/E: Z2,Dg <br /> Fee Amount: 79 .1- C1,IDD Amount Paid Payment Date D j <br /> Payment Type Invoice Check'# Received By: i <br /> EHD 48-01-02E SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />