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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5OWNEE is- <br /> OWNER I <br /> RI OPERATOR <br /> St e,e-ct l^ci v ` ) a I1 t1�e TL� CHECK If BILLING ADDRESS <br /> FACIUTYNAME COL-DSI-b'-J !5 <br /> OL-DS,)-bl-JI CY 1y IwC.IC (-�,dU ✓trt Za.1 Y) C'�t,p L, �) <br /> SITE ADDRESS 19, +V-\ S te_ 1 ITr-Q <br /> Street Nullmber Direction l 1 Sirecet.'Nlame <br /> city Zip Cotla <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2-.3 , PAA A-L-0 N 1a..7 L� <br /> /� (n� Street Number Street Namf/ ry <br /> CITY �TCN 1�� M a � STA e ZIP �t-t Sb Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 6Lt� - mol <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (5Ib) 3a 6— c) I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT, <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 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 /> -, <br /> APPLICANT'S SIGNATURE: Q• A.-A DATE: ha// I / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R <br /> If APPLICANT is not rhe BILLLNG PARTY proof of authorization to sign is required 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 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: <br /> COMMENTS: 1-tv RECEIVED <br /> JUL 2 2 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: A.. EMPLOYEE#: 2 DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: P <br /> Fee Amount: 7,7 UU Amount Paid Payment Date <br /> Payment Type 5 Invoice# Check# Received By: -<L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />