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SAN JOAQUIN COUNTY ]L+',NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# SERVICE REQUEST# <br /> 5/'�GCCi((G �3 <br /> OWNER OPERATOR �A`1E JAN t LOEREnJ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME -4pr^r ELDE fLE.rJ <br /> SITE ADDRESS I92`(Z �1 POS q5 3ln In <br /> 1��3r� rest Number Direction ree Name CiZip C de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) l O c) <br /> Stw t Number Street N <br /> CITY �,�PD STATE C-,P,, ZIP q S 3(p le <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (ZVI) �9S- y-?S2 24+S- 0-10 -3S rl1€+ ? II -D��o ', <br /> PHONE#2 Ex,. <br /> SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR fty5By �-hCCO CHECK if BILLING ADDRESS❑ <br /> I PHONE# EXT. <br /> BuslNEss NAME LIME OPtIL CrCDEN`IIRo N'l�'tt N'T'RL _ zpy -$(¢1- O"j�S <br /> HOME Or MAILING ADDRESS 40"k l� 04Nk— Sr- <br /> FA% <br /> Cm LcDy l STATE C_ ZIP -157'`-!D <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator)or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as ideatifred on this form <br /> I also certify that I have prepared this application and that the work to be performed wt7l be done in accordance with all SAN JOAQUIN <br /> COUNT' Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:r131-� I D <br /> PROPERTY/BUSINESS OWNER OPERATOR' /'MANAGER ❑ OTHER AUTHORIZED AGENT i� L�S^-('T� <br /> If APPLICANT is not the BILGING PARTY proof of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, the owner or operatdr of the property located at the <br /> above site address, hereby authorize the release of any.and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is aY�ilable and at the same time it is <br /> providedto me or my representative. <br /> TYPE OF SERVICE REQUESTED: F'tr4te-O-t SufZIFRCE * SJ$S V'{2t"7Y�t• GO/�fl tN> t�N ��PO(il <br /> COMMENTS: RECEIVED <br /> (i9,)b ` ah h/��I �. DEC 13 2010 <br /> i - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEE#: �l_ DATE: <br /> ACCEPTED BlCompleted <br /> f vE! '/ <br /> // ,,,, EMPLOYEE#: T� 4 5— DATE: �3 <br /> ASSIGNED TOS1OD"v LC.L-�S ��n� <br /> Date Servic (if already completed): SERVICE CODE: 31.E PIE' Z <br /> Fee Anwun00 Amount Paid "� 4 �- Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: i Zs <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />