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SAN JOAQUIN COUNTY ENVIRONMENTAL REALTIDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (4yr a ("�t{tre p S 6 <br /> OWNER I OPERATOR <br /> L CHECK It BILLING ADDRESS <br /> tl <br /> FACILITY NAME <br /> SITE ADDRESS,,), � ��� pa ��� 2- <br /> OZO Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Di/Aff�er/�ent from Site Address) <br /> O tea Y, C C_J�D� Street Number Street Name <br /> CITY �� STATE ZIP Zlo <br /> PH0NE#1 ExT, AIN e, tl ,b(o6 —O Ito? LAND USE APPLICATION � Z <br /> (fit) ?-- 9-3�i0 0 0Q , I o -6246 f}- O °U3yJ <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ! 2,C@ 5 J (' <br /> CON CTOR/ SERVICE REQUESTOR <br /> REQUESTOR— Go e,- CHECK If BILLING ADDRESS <br /> M 3" <br /> BUSINESS NAMEPHONE# Ex'' <br /> ' Gn $ F� erCc , 7 V 5 <br /> HOME or MAILING DRESSFAX# <br /> 630 400(0`? (ft;) 7 7C 12& <br /> CITY S2 I ZIP <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 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,STATE and FEDERAL <br /> plaws. <br /> _ `/,r, r� <br /> APPLICANT'S SIGNATURE: lNt9� r �-4J DATE: )L f 3(Ic- <br /> PROPERTY/BUSINESS OWNER❑ (/OPERATOR/MANAGER L] OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BLLLLNG 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: RECEIVED <br /> COMMENTS: /_fig. ,;._ DEC 3 1 2009 <br /> ] SAN JOAQUIN COUNTY <br /> R/,6E ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 L!Il EMPLOYEE M /,ATT DATE: ` <br /> ASSIGNED TO: f T t r, EMPLOYEE#: �/t ` DATE: <br /> Date Service Completed (if already completed): PIE: OF 0J- <br /> Fee Amount: 2 Amount Paid �p, p L7 Payment Date 31 L <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />