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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::1 <br /> OWNER/ OPERATOR pDDA <br /> -f-PtwtlL-y 'T r—vST CHECK If BILLING ADDRESS® <br /> FACILITY NAME rLOWDAry PR0PE IVTJ <br /> SITE ADDRESS <br /> 3S&3, 235&S236 ( S• ✓�'l A6.rI-F—r-A RD , yl1�F lJrEF-A �5 33� <br /> z , ° <br /> Street Number Direction Sweet Name City Zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) c(S'O y Af LE C l. <br /> L'/° i>Oa molem, Street Number Street He <br /> CITY P I Polj STATE <br /> 1'— c Zip 9 S 3(.4 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (L09 ) (noz - }v SS 2zra-uv- 3S* -34, <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ft33y QtHCCO CHECK If BILLING ADDRESS <br /> BUSINESS NAME LIVE- OA-sK- r\L PHONE# EZ . <br /> toy <br /> HOME or MAILING ADDRESS FAX# <br /> 40-4 (U 1) 3ls'i- D39� <br /> CITY LOD l STATE C.A ZIP qS)-'FO <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 be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PAR TP proof of authorization to sign is required Tule <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: 02CVICW S-0IQFi4GE 4. SJITSUIcF/FLE CONTftMwA'TIOrJ (LEpck?- <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />