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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type off Business or Property FACILITY ID# SERVICE REQUEST# <br /> W1 yk162 :=J5;20100/0/ <br /> OWNER/OPERA OR <br /> I 0 tl CHECK If BILLING ADDRESS <br /> FACILITY NAME c , 11 1`I /. � �t p IJ <br /> SITEADD E`C1TS /,Y)(06 6 TZJ ,_�Wl � �� I Lv� <br /> I15�D 67 '" a Neu bet Direction SlraH Nama CI / Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIT'�;�r [_I — STATE ZIP <br /> PHONE#f r Em APN# LAND USE APPLICATION# <br /> (707 (76 3 -,')/O << _076 - <br /> PHONE#2 E% . BOS DISTRICT LO�rI CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 A �-^^ I CHECK if BILLING ADDRESS P_ <br /> BUSINESS NAME i ,l .XYL/ F � PHONE# — E'c' <br /> ed <br /> HOME of MAILING ADDRES Cwt . L FAX# ) S <br /> CITY - 0S O1- STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> ackttowledge 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 aML <br /> o Ile performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST FED <br /> APPLICANT'S SIGNATURE: DATE: / V <br /> PROPERTY/BUSINESS OWNEPA OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> 1f APPLICANT is not the B1LLlNG 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: Ll Q it I 'J <br /> COMMENTS: RECEIVED <br /> /�/w JUN - 1 20 <br /> SAN JOAOUW COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ®(,t U t J EMPLOYEE#: 0324 DATE: <br /> ASSIGNED TO: 1L. EQ �-T EMPLOYEE III: s3&6 DATE: / /q <br /> Date Service Completed (if already completed): SERVICE CODE: 5 Z1i PIE: 4/20/ <br /> Fee Amount: (y Amount Paid 3 Payment Date <br /> Payment Type ✓ ` _ .Invoice# Check# Received By: � - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />