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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11 11 S2oo(po143 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SFEADDRES$ <br /> SVVeet Number D rectbn �� tl Street Name_ city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (SI 0r0 J ax' _TO wA_ Rd <br /> Street Number Street Name <br /> Cm C-P%STATE ZIP gs33GP <br /> STATE <br /> PHONE#1 EXT. APN# 7.45-- (UO-31. r LAND USE APPLICATION# <br /> (2040 9t0k-852-4 CAA. rf'fivKaP 245--tf00-7.4 (?(k-10-0-01 13 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> Cr$2- 5-7-49 t-Mt.e_ 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR VAwe W XJtl}/'C,O rVtA/ Yy�1Mti,` PCHECK If BILLING ADDREEXSrS. <br /> 0 <br /> BUSINESS NAME L_lV� OCje HONE# 3&9 -03-45 <br /> HOME Of MAILING ADDRESS4onr V,) C)0.' —1_ 1'� (meq)CITY <br /> - ( <br /> CITY IrO�i STATE C-IN ZIP LI 77--f Q <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 or <br /> 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: � JLd,- r DATE: `T 1 1 x 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINCPARTY 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*Jd 'qYM <br /> CDNMENTSf /�� �� u ���W✓ �.L.�.or} r ¢,'eLlf JUN �� <br /> S 4 7010 <br /> HEV -RONMF OUN7Y <br /> TM <br /> TM PIT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: O <br /> ASSIGNED TO: �— �Jj �(] �U EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5'z 2 PIE: 210 <br /> Fee Amount: d o0 Amount Paid 3 ^, Payment Date (o y <br /> Payment Type ✓- Invoice# Check# _3 0 O 3 Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />