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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S l N14(2- P, CSX-)�-q C' <br /> OWNER/OPERATOR <br /> V�/1 1 L. Q� I- �y^I <br /> FACILITY NAME CHECK if BILLING ADDRESS❑ <br /> y n, (� iW` <br /> tLi /�,� �' ^ i A,J�. t3 <br /> t.1 711$-3 3 <br /> SITEti <br /> 'ADDRESSFmAyQIJISC.4� <br /> 1, _� Street Number Direction Street Name CI Zip Code <br /> HOME <br /> r MAILING ADDRESS <br /> ADDDRiE�SSy�(if Different from Site Address) �/M i`aA(D � ` C1 2- <br /> L� ll_A � b C, �� Street Number '"` I" (•._Sttrreet Name <br /> CITY MANTi,LAi STATE ZIP 15X37 <br /> PHONE#1 'v EXT. APN# LAND USE APPLICATION# <br /> (Zoe) q - ��rG Z (V�ea r 2217 <br /> l <br /> PHONE#2 EXT. BOS DISTRICTLOCATION.CODE <br /> ( ) (- L <br /> CONTRACTOR/ SERVICE REQUESTOR �J <br /> REQUE TOR <br /> CHECK if BILLING ADDRESS <br /> L. <br /> BUSINESS NAME �/ PH NE# EXT. <br /> �- <br /> HOME Or MAILING ADDR SS FAX# ` <br /> {j ( ) <br /> CITY ' G�i�_fv S TE ZIP <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 I have prepared this pplic 'on a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar E nd EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 11-31 /-3 <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING 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: �c,I an SW \ , N <br /> COMMENTS: I_vJI CGLY <br /> 3 ?018 <br /> I�S�CLU�I✓ 2n JDAQUIN Dp <br /> DE �TAL <br /> M <br /> ACCEPTED BY: IQ EMPLOYEE#: DATE: <br /> ASSIGNED TO: wur EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: + P 1 E.- <br /> Fee <br /> :Fee Amount: jc52 c t? Amount Paid 15Z dO Payment Date <br /> Payment Type Invoice# Check# Received By: j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Z ,r <br /> 1 <br />