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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR�-bi4d <br /> CHECK N BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ESCAL" -1114 L/AA06^/ 95236 <br /> St/reel Number Direction Street Name City Zlo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numtrer Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear' APN# LAND USE APPLICATION# <br /> (ioq ) 887-3137+ x-7 3- 14v-chap 104 -10 000 9 if m s <br /> PHONE#2 ECT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ml - i <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' 1 . ,V - PHONE# <br /> 33 —(off r3 <br /> Dtwrw <br /> HOME Or MAILING ADDRESS FAX# <br /> P. 0. 0,>x Ziac.) [ZdJI 3#-c7z=j <br /> CITY L40D ; STATE CA- ZIP �S <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 application and that the work to be performed will b e in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an s L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 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: PAYMENT <br /> RECEIVED <br /> APR 19 2010 <br /> _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> a <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 'p Amount Paid Payment Date hi I-0 <br /> Payment Type Invoice# Check# -b Receive By: <br /> EHD 48-02-025 SR FORM(GoI n Rod) <br /> REVISED 11/17/2003 <br />