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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 , F Seo 471 <br /> OWNER I OPERATOR I <br /> CHECK if BILLING ADDRESS <br /> Pili-/C Ut!S <br /> FACILITY NAME <br /> SITE ADDRESS ZZ,4S 5 v"•Yr ci5ZO5— <br /> ZS jp StreetNumber DiLion F to,,L Street Name CCibJ ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 17,2-q Qp Street Number Street Name <br /> CITY STATE ZIP <br /> t C11+ TZ� <br /> PHONE#1 Ext. qpN# LAND USE APPLICATION# <br /> (2c ) 9S7-39-31 N, -40 + Lit <br /> � '• P4- - OGV0O3W0` <br /> PHONE#2 E'R' <br /> CONTRACTOR/ SERVICE RE( D f sl ewe e/ <br /> REQUESTOR �- <br /> 1 <br /> BUSINESS NAME <br /> Zfro�r76 � z�l��o{�I <br /> HOME Or MAILING ADDRESS ' <br /> CITY S aJ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business Ca M1� twt5ti <br /> � <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPART "+ <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 perform, D'raL"`� ''��"" <br /> 4 A''"d�J1af 'I"o c.o fS'GLt v.a'l"fk <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE::[` I Lot o L <br /> PROPERTY/BUSINESS OWNER OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENTL# }I�� <br /> IfAPPLicANT is not the B11,LING PAR proof of authorization to sign is required t 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 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: <br /> COMMENTS: ECE�VE 7 <br /> SAN JAIV 2 0 2006 <br /> H At j jD/vMFRE: <br /> Ou TV <br /> ACCEPTED BY: EMPLOYEE#: DATEASSIGNED TO: EMPLOYEE#: SQ tL DATEDate Service Completed (if already completed): SERVICE CODE: ���� <br /> Fee Amount: 6 Amount Paid 1 D (o , OD Payment Date \1 ZZI 66 <br /> Payment Type v- _ Invoice# Check# 'a 3 b Received By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />