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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COD,5J-'3C)� <br /> OWNER/ OPERATORff <br /> �/ C�7/ ^.9,45N <br /> FACILITY NAME /V CHECK If BILLING ADDRESS <br /> SITECADDRESS t T /�J ` q <br /> J �v �Z � <br /> Street Number Direction Street Name ✓7oGe-DDA Ci I �2 7 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7<'-7'Z') ( (�L70� /-�✓ Street Number Street Name <br /> CI�T� STATE ZIP <br /> 'VC.2TA' y�YK�ooL e 11 c,loD <br /> PHONE#IT N# LAND USE APPLICATION# <br /> 7Iqs <br /> (moo) o S- Z Sq 7 - <br /> PHONE#2 EXT. FQOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE UESTOR <br /> p CHEC .LING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> l7/,(�- r//41�.rY >%n/,�k.0//✓(� (gat ) Sz ``/Z�� <br /> HOME or MAILIN9 ADDRESS FAX# <br /> ilt 7 ` -' r, (W-1 ) jz6- o3 <br /> CITY �l/16L)E57o STATE 64 <br /> ZIP gfj5 • <br /> BILLIING 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, T E and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: /p, DATE: lD/� l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/)\TANAGER ❑ OTHER AUTHORIZED AGENT 0 —'S Op—V P <br /> If APPLICANT is not the BILLING 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: <br /> COMMENTS: - ZI-'98 hA <br /> �t/08 RECEIVED <br /> OCT 1 6 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: HEATE: <br /> ASSIGNED TO: EMPLOYEE!:g?<4-C/.(- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: t J' Amount Paid '� �Cl Payment Date CCS I G <br /> Payment Type Invoice# Check# 30 �3 Received By: <br /> EHD 48-02-025 SR FORM(Golden_ 'Rod) <br /> REVISED 11/17/2003 <br />