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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ES/DENT/AL euZ SROa to3� <br /> OWNER I OPERATOR CHECK If BILLING ADORESS❑ <br /> /27R. /7R4• AALPAf AAID Do/ROT k/ <br /> FACILITY NAME <br /> SITEADDRESS .5'.g 00 W y,,,,,4,,r 2D- 'TRACE/ 9530 <br /> Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheat Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION III <br /> 3/0 _45_ <br /> s o�-rrooz2U 4s <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DVAI <br /> BILLING ADDRESS Er <br /> C ESME H <br /> BUSINESS NAME ��C O L PHONE# O� EXT. <br /> CAFHOME or MAILING ADDRESS L FAX If <br /> P. o . Sox 37 I ) - s <br /> CITY STATE L?A <br /> ZIP q5-3 61 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FED ws. <br /> -IVAPPLICANT'S SIGNATU 16. DATE: <br /> I ��— / — <br /> PROPERTY/BUSINESS OWNER IJ OPERATOR/M NAGER ❑ O ER AU THORIZEDAGENTIS <br /> /,fAPPLICANT is not the B/LL/NGPARTY proof of autho zation 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:$GUR-FaAPAA, Igo <br /> E' p <br /> COMMENTS: j RECEIVED <br /> �a,,a,,,11 •� 40!5 NOV — 7 2011 <br /> SAH-'OAQU&4 COUNTY <br /> EIMRONMEMAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY' EMPLOYEE#: DATE: � � Z <br /> ASSIGNED TO: 0 EMPLOYEE#: DATE: D <br /> Date Service Completed (If already C mpleted): SERVICE CODE: 3/S PIE; <br /> Fee Amount: Z �� V'�/ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />