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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 I OPERATOR <br /> ,, <br /> SY'e / r�< �v^S` L L CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r� <br /> 258, l t\ sit Cc��v vY Nam <br /> Street Number Street Name <br /> CITY STA ZIP <br /> I"4Dr��;� C. �%.JLv V..-o✓G- CSA 4551 <br /> PHONE#1 � Enr• APN# Q Q't LAND USE APPLICATION## <br /> 6•00 /�/ ( ✓ <br /> PHONE#2 ExT. BOS DISTRICT /� LO(ION C DE <br /> ( ) 11 U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> 4V1� C4V CW\ CHECK If BILLING ADDRESS <br /> BUSINESS NAMEc� PHONE# Em <br /> IIz5 <br /> HOME Or MAILING ADDRESS Fax# <br /> -Z 58 5L'<-: (4Z5 ) 245 �9cy <br /> CITY _LvGJyti..+ STATE LA ZIP '7./5,31 iC <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,StandardsV and F laws. I/ <br /> APPLICANT'S SIGNATURE: DATE5 <br /> ,:/ 2310 7. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L7 <br /> LfAPPLICANT is not the BmLLNG PAR7T,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 envirommental/site assessment <br /> information to the SAN JOAQUTN 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 <br /> COMMENTS: AFN+* 2a9 -a3o-oz Ds -OS I1 -(2 , I%, 23 u!- OZO Z3 , <br /> /I l �AQIU4* 2U1- G3e- 03 ,-uy, -�s.1..P3 , 209 -040 -02 `SAY 23 2007 <br /> SAN JOAQUIN COUNTY <br /> H�VIRONMEN-- <br /> ACCEPTED BY: ,JJ EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: a 3 <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 />