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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/OPERATOR CHECK If BILLING ADDRESS <br /> ED <br /> b <br /> FACILITY NAME <br /> SITE ADDRESS H M&I LA h L / ► <br /> Z3Street Number Direction I Street Name citvZ( Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 12 t)._ <br /> . V Street Number Street Name <br /> CITY 1.be ke4r-oi STATE ^ zip <br /> PHONE#1 ExT. APN# LAND USE AAPPLICATION# <br /> l Zig) 7271 ' 02,02- (Nome) a67-040 -ol 7 PR l3bod$v <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> m Ito) to - /501 CLQ ) o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR lshavY1 �Vll` <br /> $. 4w,f CHECK if BILLING ADDRESS <br /> BUSINESS NAME �% � � ✓✓r � PHONE# ExT. <br /> HOME Or MAILING ADDRESS # <br /> 0. & ; 80 (7M) <br /> 35d/- 6-77-3 <br /> 7 2-3 <br /> CITY la <br /> �,1% STATE w/i i!ZIP 6Zl, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized argent 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,StandZr�z� <br /> / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ 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, 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: S oil k ` S <br /> COMMENTS: / <br /> 13/l� 3 f /CF RECEIVED - <br /> z na✓tctdr-,n 'VQ JAN -3 201 <br /> SAH,IOAt]UN COUNTY <br /> f lam/ /j9%A1) ENVIRONMENTAL <br /> I HEALTH DEPAKMEW <br /> ACCEPTED BY: ( T-A,,- EMPLOYEE#: DATE: I f LA <br /> i <br /> ASSIGNED TO: t,:7k� J EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 2 5 p 7�1 Amount Paid — Payment Date f <br /> Payment Type Invoice# Check# a eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />