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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> ]F� <br /> W& ti.4 3 $' <br /> OWNER/OPE TOR <br /> CHECK If BILLING ADDRESS <br /> t 2 <br /> FACILITY NAME - <br /> SITEADDRESS o2ia.68 EDirection AVaNfk CSCALO1! 'S3w <br /> Street Number Street Name Cit Zi Clde <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 15,4&7c- Street Number L Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Eta. APN# LAND USE APPLICATION# <br /> 0091 SS/ -/dVa N <br /> PHONE#2 Ea-,. I BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (�O/J CffESN� PHONE# E%TCNECNIfBILLINGA0DRE55 <br /> BUSINESS NAME o70 LG $-� 03 <br /> C/-�EI�IE C'oiL/ � �,� <br /> HOME Or MAILING ADDRESS FAx# <br /> (2172 1 Ira e - <br /> CITY / (2 LO STATE CA <br /> ZIP ^S-3 <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 /> [ also certify that I have prepared this applic 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FED laws. .J <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/ZAGER ❑ CAER AUTHORIZED AGENT <br /> 1fAPPL/CANT is not the Biar;yg PARTY proof of authorization 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 enviromnental/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: IX ( D w 0#4-11Z- <br /> COMMENTS: „ I� M.I J L &'k <br /> � pECE9VE 4 <br /> Y/z3/if�+�Ji.. 4lul�l� rt~w14 �t� . , APR 15 2014 <br /> C MS' 1:x•.1 :r t SAN JOAQUOUMV <br /> EWijOVIEWAL <br /> UFALM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: o EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E. aO <br /> Fee Amount: oZ5"b�' Amount Paid e9 Payment Date h l <br /> Payment Type Invoice# Check#� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />