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•1.I + +14 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER J OPERATOR Q ^ ✓ <br /> r,�- Li-t�� O 12-10 ,r� \ r I-"" CHECK If BILLING ADDRESS <br /> y� <br /> FACILITY NAME <br /> SITE ADDRESS -7+3 P D55TA L 952- <br /> �4d,5 `/NOtSnI 3 <br /> Street Number Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 20001 FL_ccE> P-ao <br /> Street Number Street Name <br /> CITY LI n1 D E!� STATE C_4 ZIP o'S 23fo <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> o¢ PA - 05- 2-'7 '11ti5 <br /> PHONE#'I ' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> KA t�-6 1-t- CHECK It BILLING ADDRESS <br /> BUSINESS NAMEu��Y PHONE# EXT' <br /> Dtu--o n► M <br /> HOME or MAILING ADDRESS FAx# <br /> P,0, [3ox Z18o (7,> ) 334-0-7Z3 <br /> CITY1 �1�t STATE ^ ZIP GI4-5 I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAI:iII DEPARTMENT hourly charges associated with this project <br /> or 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> T <br /> PROPERY/BUSINESS OWNER OPER dkr'. <br /> \TOR/.NIANARyy��77 OTIIER AUTHORIZED AGENT 0 <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereb} 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: <br /> COMMENTS: /C `�� ,�.- _ REL, /ED <br /> SAN JOAQUIN COUNTY <br /> INIAL <br /> ENVIRONt ACCEPTED BY: EMPLOYEE#: r DA ��� G <br /> :tj <br /> s� <br /> ASSIGNED TL r EMPLOYEE#: DATE: <br /> Date Service Cotnpleted (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: (� `` Amount Paid 4 8l� D� Payment Date D <br /> Payment Type ✓ Invoice# Check# �-�� Received By: <br /> EIID 48-02-025 SR FORM(Golden Rod) <br /> RFVISFn 1 ttnnnni <br />