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SAN JOAQUIIL OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L' L U L –PRO O ED s 1DevTtAL S" L�� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> DAvIO 1A O/2 /O AND RON 34R-BEP <br /> FAcany NAME ,�,t <br /> SITE ADDRESS S 5-fnA L L. /Z0.4'� I 'A NT1-G/} 7533/ <br /> /0 C' Street Number Direction Street Name C' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /r/ l 5/i'/A Street Number Street Name <br /> CITY - STATE LP <br /> PHONE 01 �• APN# LAND USE APPLICATION# <br /> yw - 2 / � - o •-2 A - 03 - 577 <br /> PHONE#Z Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS LU <br /> BUSINESS NAMET PHONE# En, <br /> /_ /V CO AIS Gl O ✓'J C g- 1403 <br /> 0 <br /> HOME or MAILING ADDRESS9I FAx# <br /> / � Or BOX 37'14 <br /> CITY T' C STATE /t LP /J J <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 ap )kation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1rAPPLJC4NTisnotthe B1LLrNGPeRTY 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, 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 REOUESTED: O/L Scrl7Ad/ iT W-EV(rvLlPA�YM <br /> COMMENTS: I VE❑ <br /> AN 10 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Ur L 1 ul'E I ,q- T EMPLOYEE#: 3 2-1 DATE: C f G G <br /> ASSIGNED TO: t� ESS P` ,A EMPLOYEE �S'(� DATE: 6 /O 0 <br /> Date Service Completed (if already completed): SERVICE CODE: SZZ- P 1 E:2(0• G/ <br /> Fee Amopnt: O Amount Paid - — Payment Date p <br /> - Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />