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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P+A6LI- LAIILITy <br /> FL6Tal6 60. SFeJwE GEfAI EC <br /> OWNER/OP11RATOR <br /> CHECK if BILLING ADDRESS <br /> PACAF14 &AS AND EWLT'i"t- NV <br /> FACILITY NAME <br /> TOPE <br /> SITE ADDRESSSTot.lao1J 9sym4 <br /> N DIDTH WEA LANf, <br /> 4040 Suael Numbar Direction i city Zip Code <br /> HOME or MAILING ADDRESS (If Different from She Address) <br /> Sireel Number Str.w Na.. <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION If <br /> (e09 ) S 9 z-15 L(o <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADORESS� <br /> t/ Lr <br /> Exr, <br /> BUSINESS NAME PHONE <br /> # <br /> tArLA01 o N1tL.Yt atcwl. WL• SYO 10-Bry 103 <br /> HOME or MAILING ADDRESS FAx# <br /> s - (Sio ) 4 <br /> JV-43 <br /> CITY sA• bKLwymj STATE L A ZIP 9 Y 577 <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. HEALI Ii DL-PARTMF.N1hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 FFDERAL laws. <br /> APPLICANT'S SIGNATURE: �I�r - �9 DATE: <br /> PROPERTY/BUSINESSOWNER❑ O,caArort/MANAGER ❑ OTHERADTItDRIZEDAGEMr Ifd <br /> IfYIPPLICANr'is not the 13114.1102 P/18T) proof ojauthorization 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 ENVIRONMENrAL HEAmH DEPAR'rMFN'r 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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Data Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />