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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 41"'7E2CIAI 0WfTR/ L S t D Z 3 <br /> OWNER/OPERATOR <br /> L L-C CHECK it BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS E 57-gri5 111�-IYWAIV ff 1�491- STOCKTon/ 9S <br /> 213 Street Number Direction 496/ A Street Name Ci ZI Lotle <br /> HOME Or MAILING ADDRESS (it Different from Site Address) YJ f�20NTM1B RoAO <br /> Street Number Street r-4 <br /> CITY $TATEZIP g2 I <br /> STcKToN C ^ <br /> oFh q <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 2 - �/v t9 4j 1 - /7e2 --30 eA - O 3 -!o7 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Al CHECK It BILLING ADDRESS <br /> BUSINESS NAME G,�ESN� WA/l�Lr PHONE# �G Ex, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY L C7 STATE A Zip <br /> < <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 <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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S T and FED S. p <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ <br /> NAGE ❑ O ER AUTnORI7,ED AGENT <br /> If APPLICANT is not the BILLTNO PARTY proof of auth rzation 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, 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 at the same time it is <br /> provided to me or my representative. MENT <br /> TYPE OF SERVICE REQUESTED: SO/,L SU/rAAj314 tf7-4 D E vl vV <br /> COMMENTS: y r, 2004 <br /> �j SAN JOAQUIN COUNTY <br /> LLFIEENVIRONMENTAL H <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CDDE: I IPIE; <br /> Fee Amount: Amount Paid _ Payment Date /( / <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 45-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />