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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY 1D# SERVICE REQUEST# <br /> 6"D 690 7:3.4 <br /> OWNER 1 OPERATOR 1-6vti -1>1 x p J CHECK ifSILLINGADDRESS <br /> ® <br /> FACILITY NAME -P 1 x 0 ry P 12a Pf.RT"y <br /> SITE ADDRESS9-2--+3 �. . .} N Afo-r --�. Ar-A VA P v <br /> Street Number Direction <br /> Stree Name Cit ZipC de <br /> HOME or MAILING ADDRESS (If Different from Site Address) ���.�� E H A(L►.)�y L�. <br /> Street Number treat Name <br /> CITY Lpn` STATE C A ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (7-01) So oc�� - 3to- to PPr -I000z)-+ F <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> REQUESTOR a�J t E µ CHECK if BILLING ADDRESS❑ <br /> PHONE# Ext. <br /> B(1SINE$SNAME LIvE d�K & U��J►1RQ1+1t/v1�NTAL_ _ Zo 3(.01- 03S <br /> HOME or MAILING ADDRESS FAX# <br /> '-I-u� Imo. OAtK- ST. (dq -03�� <br /> CITY Lob t STATE C ! <br /> —Z- <br /> IP q S 7-y v <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 a',ccordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. �f / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PRQPERTY/BUSINESS OWNER❑ OPERATOR/MA AGFR C1OrITER AUTEIdRIZED AGENT 13 <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 operatdr 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: IQeQ t 4LvJ 50( L- 9%J tT^ M31 l_tT� 5RT-V-Dl qY,t <br /> G� AUGCOMMENTS: Q�L011O t/r 3/r-V A AED <br /> j �L712Q/r �� s4NJo 6 2010 <br /> H �NVIAO UiN CpU <br /> �CroMeiJ, bra=,°����N7 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: ° DATE: <br /> �SERVICEDE: �.7PfE: <br /> Date Service Completed (if already completed): G Q <br />' Fee Amount: Amount Paid Payment Date f <br /> Payment Type ✓r GGG Invoice# Check U�g oC 3 0. c3� Received By: <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />