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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /SES/OE�T/A-{L /NE RD W`� " O7S <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ <br /> -9/LL S4 S5MP1-(AA//5 PR/OSTM <br /> FACILITY NAME <br /> SITEADDRESS g3sp�g339 WEST L/NNE ,PaAD TRiiCy jS3oy1 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 93 [t/ESr L/A✓A/£ Street Number Street Name <br /> CITY STATE ZIP <br /> Tj7A4 c <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( ) 033- q46- .7-4- 3-210- 31,9 PA -os - b 3Aa J-Vao5oZ-570 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTQR - CHECK If BILLING ADDRESS <br /> �O/✓ eflE.fivc <br /> BUSINESS NAME PHONE# Ext. <br /> C S/V oNSUL 03 <br /> HOME Or MAILING ADDRESS FAX# <br /> • O • f3o ( ) <br /> CITY R G O STATE A ZIP 9s38/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator orauthorized 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 appfi tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEUKXLaws. <br /> APPLICANT'S SIGNATURE: DATE: 3 la- aG <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 7 MANAGER ❑ THER AUTHORIZED AGENT <br /> JfAPP6iCANT is not the BtLL/NGPARTY proof ofi orization 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 isail —S time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUE ED: A//rlm'fr AD/N! S014- JADtk/ 5 ES .E <br /> / QED/TE7J £ <br /> COMMENTS: 7' J3 V6 � �i6 o(.,T�e RECENED <br /> "-f�j�j , MAR 1 U 2006 <br /> Ulm COOS-" <br /> SAN JVIRONMEN AF <br /> NT <br /> ACCEPTED BY: _ ^^ ,n Q 1500EE#: 0 t4 & DATE: D O� <br /> ASSIGNED TO: �.� `V EMPLOYEE#: go <br /> S DATE: 0 D 6 <br /> Date Service Completed (if already completed): SERVICE CODE' Z ri I E: 2&Q 2_ <br /> FeeAmount: fb-7 1 <br /> Amount Paid7 t^,, Paynfent Date 3/10 C <br /> Payment Type Invoice# Check# �I. Received By: <br /> EHD 48-02-025 .SR FORM(Golden'Rod) <br /> REVISED 11/17/2003 <br />