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SAN JOAQUIN COUNTY ENvIRoNMENTAL HEAL'T'H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST 9 <br /> IE 11 <br /> OWNER/OPF�RATOR CHECK if BILLING ADDRESS O <br /> LL c <br /> FAcanY NAMEK/1/�V t' / ./ p <br /> SITE ADDRESS <br /> G /COGLc �(JLKG ela3 7 <br /> /Z 411 -A) Street Number I Direction SI ame CI Zip Code <br /> HOME or.MAILING ADDRESS (If Different from Site Address) <br /> 11VLE Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# / <br /> ioM - 7l) CSr-3zo -.>z- <br /> PHONER Ea*- SOS DISTRICT LOCATION(Z'05 ) 3 — <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 4orREQUESTOR p <br /> CHECK If BILLING ADDRESS13- <br /> BUSINESSNAME _ L•_ Cl PHONE# ExT• <br /> 7a <br /> HOME or MAJUNGADbAESS FAX# <br /> Z 70 Loi c Zv5) -3 —vim 8�i <br /> CITY J - p STATE LP 7 <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 fomL <br /> I also certify that I have prepared this application d t at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and ED•RAL laws. / <br /> APPLICANT'S SIGNATURE: A DATE: <br /> PROPERTY/BUSINESS OWNER OP BATOR/MANAGER Er V OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required rime <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 /> infomtation t0 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: l- L i nG S' h z Z <br /> COMMENTS: RECEIVED <br /> a, -EP - 92002 <br /> SAN JOAQUIN COUNTY <br /> HEALTH SERCES <br /> • ° � //'�+ ENVIRHNtH <br /> MENIIAL HEAL N <br /> CDIVISION. <br /> APPROVED BY: EMPLOYEE M ` ( DATE: <br /> ASSIGNED TO: 0 - EMPLOYEE#: Q DATE: <br /> Date Service Com ted (If aI ady completed): SERVICE CODE: .-Z P I E G(, C/L <br /> Fee Amount: S Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST <br /> ' REVISED 6-5-02 <br />