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SAN JOAQUIV- *70UNTY ENVIRONMENTAL HEALT- -JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> j10 2 -7 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> NA l-A Po /E LLG <br /> FACILrrY NAME ` /� <br /> SITE ADDRESS FORT/-/ fLJ//.f/klAl C19 F/ZUIvT E RD- STOG KION 9sZ IL <br /> /O La Street Number Directio``n77 / Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 'r, AC( A Street Numbef Streel Name <br /> CITY <br /> STATE CA ZIP a n Lvn <br /> STo <br /> PHONE#t ExT' APN# LAND USE APPLICATION# <br /> ( ) -VO / 09-0 - 070- 07 - - / <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADORES <br /> PHONE# Em <br /> BUSINESS NAME if <br /> qf—:� nfE� (foNsut- AIC I 0_ <br /> l o <br /> HOME or MAILING ADDRESS FA%# 6 / <br /> P.O . 0 t ) d-7-J5 <br /> CITY L STATECA ZIP q <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 appy tion and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FE L laws. <br /> APPLICANT'S SIGNATURE: DATEE:/ G -Z7'OS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ O IER AUTHORIZED AGENT'pCL <br /> If APPLICANT is not theBILLINGPARTf proof ofautho Ization 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: SU t C N K NT / D �E PO KT t <br /> COMMENTS: <br /> I�aZ7 ReJta��D � �� ,� 2007 <br /> S-1 <br /> .. v r J a'S� S.)� SAN�p OUtME�T LTY <br /> y a. � EC1VlRDEPPRSMENT <br /> ACCEPTED BY: �` O„ l�� EMPLOYEE#: / DTE: / 7 05— <br /> ASSIGNED TO: �S �-� �"�(-� EMPLOYEE#: �� DATE: b� <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid /b. c z) Payment Date /ot//JC.�S <br /> Payment Type Invoice# Check# X33 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />