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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property �F/} > Z p-C) <br /> [� I <br /> OWNER I OPERATOR CHECK if BILUNO <br /> r, N11ram <br /> FACILITY DAME <br /> Viramontes Pro ert 95240 <br /> SITE ADDRESS 14454 N State t Name 8$ Lodi <br /> Ci Zi Code <br /> Street Number Direction Street Name <br /> HOME Or MAILING ADDRESS (if Different from Site Address} P,�. BOX 2244 <br /> Street Number Street Name . <br /> STATE ZIP <br /> CITY 9,5241 <br /> L d Exr APN# LAND USE APPLICATION# <br /> PHONE#1 PA-03-543 <br /> ( } � 9 063-16 -1 1 - <br /> SOS DISTRICT LOCATION CODE , <br /> ff E <br /> PHONE#2 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> Ff3USINEss <br /> UESTOR CHECK if BiLuN�SS� <br /> PHONE# Exr <br /> NAMEFAX# <br /> E Or MAILING ADDRESS (209 1 3 9-4228 <br /> 209 369-4228 STATE ZlP <br /> CITY <br /> Lodi <br /> I 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 be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and.FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r <br /> PROPERTY/BUSINESS OWNER❑ U OPERATOR/MANAGER <br /> ❑ OTHERAUTnoRIZEDAGENT <br /> If 4PPLICANT is not the BILLIN� proof of authorization to sign is required �fl <br /> AUTHORIZATION TO RELEASE INI,ORMATION: When applicable,I,the owner <br /> or operator of or n the pr n� <br /> above site address, hereby authorize the releas � cats d at the <br /> e of any and all results, geotechnical G �BV it is <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and int s e t>CODso <br /> provided to me or my representative. it3 <br /> r i~tyV1Rd�PARTM� �' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: `�tG "�.0 /V!. U11� W•'_�' V � ,� 3 /'`.�. <br /> /BY: DATE:, �7 p <br /> APPROVED EMPLOYEE#:', f/f <br /> z EMPLOYEE#I � DATE: <br /> ASSIGNED TO: <br /> .. O <br /> Date Service Completed (if already completed); <br /> SEMI COIIE:. PIE: <br /> h Amount Paid �� r--- Payment Date <br /> Fee Amount: V <br /> Check# Received <br /> Payment:Type <br /> invoice ft. <br /> - �(o By: <br /> SERVICE REQUEST FORM <br /> EiHD 48-01-025 <br /> REVISED 6-5-02 <br />