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SAN JOAQUIN ' OUNTY ENVIRONMENTAL HEALTIT nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c SERVICE REQUEST# <br /> ,yJZ.00 COO/L(-Z <br /> OWNER/OPERATOR013EfLTS0J CHECK if BILLWGADDRESS® <br /> FACILRY NAME -SDN P(,7+p(�t(jT� <br /> SITE ADDRESS Zol e'�'U S . L E tt VOW& Iz1?. T(�"t�C-y g S 30t-{ <br /> Street Number Di'210n St re t Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) •7-T33-} S• g/tt.JT N �n <br /> Street N, Street Nam <br /> CITY T{Zh``` STATE C^ ZIP 91c;-3o4 <br /> PHONE#1 l EXT' APN# LAND USE APPLICATION# <br /> 0091 91•}- 13'12-- Z53 -330 -10 Fk- I000tDC <br /> PRONE#2T- BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dh-qt I/V eL—CIA CHECK If BILLING ADDRESS <br /> PHONE# Exr. <br /> BuswessNAME Lt�f1; phlL GEOENVtR-oNmENTR� �g 3taq -o'3�S- <br /> HOME or MAILING ADDRESSFAX# <br /> L+O-} W • OPtK 9,T-. ( loq) 3ta9 -o345 ' <br /> CIN Low t <br /> STATE Cpt ZIP 9 SJ-4Z) <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: Q /s em DATE: -SLyyzlb <br /> PROPERTY/BUSINESS OWNER IP OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: ?-F-%A EVv SOl L S l.J ITI\ 5X Lt" STV-P\( <br /> COMMENTS: �j g �� „� /6 o,.t.-l� RECEIVED <br /> ) .Pwaro ® JUN - 4 1010 ) <br /> SAN JOAQUIN COUNTY- <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I EMPLOYEE#: DATE: <br /> ASSIGNED TO: O �� EMPLOYEE#: O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 57-2 PIE:2AQZ <br /> Fee Amount: Z 0 00 Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By. <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />