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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T ne �LL$reoD ce3,ggq <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> R - 177,4_7!5- PH Av <br /> FACILITY NAME <br /> SITE ADDRESS ,6-300 W �,cf/YJ,4 2D_ T.-A C 953 - <br /> Street Number Direction Street Name CI ZIp Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PH0NE#1 ExT• APN# LAND USE APPLICATION# <br /> i291493 -bo / -'5-3 - -3119-45 2A - 1,10 a,:zz o <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) QC <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 5 <br /> I � CHECK if BILLING ADDRESS <br /> Do <br /> BUSINESS NAME 5 PHONNE# ExT' <br /> -5&fnfu�T - o <br /> HOME or MAILING ADDRESS FAx <br /> 0 • 0 7 ( ) ZS- <br /> CITY QG>� STATE CA ZIP <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 <br /> or 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, TE and FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE:_ <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR NIANACER ❑ OTHER AUTHOR1zED AGENT 0 <br /> IfAPPLICANT is not the BILLING PARTY proof Of authorization fo 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: -j0v[. L4alzl K/ RECEIVED <br /> COMMENTS'. P"w� DEC - 9 2011 <br /> SAN JOAQUIN couNTY <br /> EMtIRON)AFSTAL <br /> I HEALTH DEPARTIAEN7 <br /> ACCEPTED BY: oc-E.L/E- EMPLOYEE#: Q Zr DATE: 2- <br /> ASSIGNED <br /> ASSIGNED TO: '—rA- EMPLOYEE#: L&O tom[ DATE: !� f <br /> (late Service Completed (if already completed): SERVICE CODE: r'Z� P 1 E: ��f <br /> Fee Amo unt: j p,d--?) Amount Paid b Paym�eJnt Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> REVISED 11/1712003 <br />