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NANJOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A rrs /- -,e ,4- T'5�CU-500eg_ <br /> OWNER I OPERATOR <br /> 177 <br /> /Z . SL/ KK�2 CHECK if BILLING ADDRESS� <br /> FACILITY NAME <br /> L/ E <br /> SITE ADDRESS (4ZZZ G(/fE R/Pp/t� y�366 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) / ..u/5E <br /> Y <br /> Z Street Number i—Sh/reet Name <br /> CITY STATE ZIP <br /> Q/P c� 5-36 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION At <br /> ( ) gZ - 6 '0 -azo-3s <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> E CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em <br /> E Al,6C'OAIS L T/A/( 4o _ o <br /> HOME or MAILING ADDRESS FAX# <br /> P. D 0 3 7174 1 ) vl,6g -�5- <br /> CITY -r R <br /> L 621- 14 STATE ZIP / <br /> BILLING ACKNONVLEDGEMENT: 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,S E and F L laws. <br /> APPLICANT'S SIGNATURE: DATE: 3 -ZB-O; <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLLNG 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 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: CE 4(S CON EPO2� i <br /> COMMENTS: 7 1 , j �[il�j r7,«.� REC <br /> MAR 2 S 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Fp LTH DEPARTMENT �7 <br /> ACCEPTED BY: EMPLOYEEM Q DATE: `0 / <br /> ASSIGNED TO: EMPLOYEE#: E: 3—.-'!-&V7 <br /> Date Service Completed if already completed): SERVICE CODE: TIS I P 1 E: <br /> Fee Amount: - _ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: -: <br /> EHD 48-02-025 ' .SSR FORM:(.Golden'Rod) <br /> REVISED 11/17/2003 <br />