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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> swipa 12 7 S g2 <br /> OWNER/ PERATOR {I — / /'I(� �I � � CHECK If BILLING ADDRESS <br /> FACILITY NAME I Vl Qh 4' ! ikc <br /> SITE ADDRESS L90(v- E• r, n n h , C�ow <br /> Street Number Diredlon Ute' t eet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different fr m Site Addr f) (/�/y'\ /�_'^ d <br /> Street Number ( I I <br /> CITY S T ' IP —77 <br /> 071 <br /> PHONE#1 E�' APN# LAND USE APPLICATION# <br /> y ) L/ c?- 1 164-((" <br /> PHONE#2 Em BOB DISTRICT Locxno CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTORAlm CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE EM' <br /> HOMEor MAILINGAD ESS FAx# <br /> (-953f di t-10349 <br /> CITY STATE ZIP 0 <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 ENvmoNmENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> 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,S and FEDERAL,laws.' l <br /> APPLICANT'S SIGNATURE: I /7�h /p �� ,w DATE: �4�9/0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT'S <br /> IfAPPLICANT is not the B7LLlNG PARTY,proof of authorization to sign is required Pf 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 environmentallsite 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: [�_ST ,O� t� Fl—� RECEIVED <br /> COMMENTS: OCT 9 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L U I !�+'4 EMPLOYEE#: 0-2, 2, DATE: <br /> ASSIGNED TO: ,c �,,�,2 EMPLOYEE#: J!'& Z DATE: 1 O 2(O <br /> Date Service Completed (if Iready completed): SERVICE CODE: ( Q PIE: �34)C� <br /> Fee Amount: cr LF , Amount Paid �� l 'I UD Payment Date �0(� i)-7 <br /> Payment Type ✓ Invoice# Check# 1:000 Received By: <br /> EHD 48-02-025 ',,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />