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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L o u 5 C' (✓ S <br /> OWNER I OPERATOR <br /> THE D C L 2ft:L CENTE2 `30AKD CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> S /.VD C! 2st L ,yD C'Or✓IMGlN/T �.�t/TF2 J <br /> SITE ADDRESS 4715 FOPfZ/AAl0 rjToG/Lr{!/t/ 9J 3L4 <br /> 51real Number Direction ama City Z,p Code <br /> HOME or MAILING ADDRESS (N Different from Site Address) <br /> 9treal NumberStreet Name <br /> CITY STATE ZIP <br /> PHONE#1 E- APN# LAND USE APPLICATION# <br /> ezo- 937 o5-- 3/0 - /�2 Pq - /000-277 <br /> PHONE#2 Exr' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> / /OA1 CNECK If BILLING ADDRESS <br /> BUSINESS NAME J/V PHONE# E'T' <br /> E5 Co.�rSG«T/•�/( 668- 3 <br /> HOME Or MAILING ADDRESS FAX# <br /> Pe - 130Y 37 (;ko9 ) 6GS-259 <br /> CITY )Z L OG/� STATE CA, <br /> 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[his appli �on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,5 E nd FEDEW laws. <br /> APPLICANT'S SIGNATURE: DATE: 9-7-11.1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ 0�14ER AUTHORIZED AGENT <br /> If APPLICANT is not the B/LLIrvc PARTY proof of authorization to sign is required Time <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 JOAQUfN 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: /V/TR RAD/n(L Aqt4 Y MEN <br /> COMMENTS: <br /> 7 2012 <br /> /7 F. E 5C�' v �Q l'•" S/ "",R OEPAETTN <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: O <br /> Fee Amount: "' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By:- <br /> i <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />