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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S ce &"364 <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS L�330 r c/-'7'-I 1r�Z IZD• 1 X570 <br /> SlmtName C' 21 Cotla <br /> Street Numbor Direction 7� QQ��J�J G1 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (�•d I.JL)l` I 1-7 <br /> Stmt Number Slreet Nama <br /> CITY r' STATE C,A ZP q!�� <br /> W fit. �N# LAND USE kPPLICATON# /7 <br /> PH'O�Np#1 O13 ' OZ� - I PA - 11 Do I yS <br /> (W,EI f`- I 1 BOS DISTRICT LOCATION CODE <br /> PHONE##2 2 E"' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �,1 _u N AAA , ,' I� CHECK If BILLING ADDRESS <br /> r' A �`��rTr-F-c PHONE# 2 Ezr. <br /> BUSINESS NAME �11 1 n(V f M L)Q-P Zcm J'?J��� <br /> FAX# <br /> HOME Or MAILING ADDRESS 1^D <br /> CITY STATE C ZIP 9I5Z4 / <br /> LbDf l/•� 717"' <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 aA FEDERAL ws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT Ea- SvOJFVD2 <br /> If APPLICANT is not the B/LuuG PARTY proof of authorization to sign is required nue <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: S O i L S r..c i'j ��(t i Y—L S'Jzt/' <br /> PAYMENT <br /> COMMENTS: Z//�f��I ,� ' RECEIVED <br /> Kt5PG7% <br /> OCT 0 6 2011 <br /> SAN JOAQUIN COUNTY <br /> FNNRONMENTAL <br /> EMPLOYEE#: CJ,.3 Z I DATE: I, (v if <br /> ACCEPTED BY: d L t L,,E i 1,— <br /> ASSIGNED TO: CS C p Tr4J EMPLOYEE#: 57-;'*c/ <br /> Date Service Completed (ff already completed): SERVICE CODE: C---2! 2, PIE: <br /> Fee Amount: Amount Paid - .:ZS C t rL Payment Date <br /> fro •L� <br /> Payment Type/cEl,t=C_j�- Invoice# Check# Zv(_S Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11117/2003 <br />