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SAN JOAQUIN COUNTY ENVIRONMEN UESTALTH DEPARTMENT <br /> SERVICE REQ SERVICE REQUEST# <br /> FACILITY ID# 00-11 <br /> Type of Business Or Property <br /> CHECK N BILLING <br /> OWNER I OPERATOR <br /> Lathrop 95330 <br /> FAcamNAME Th Do ho ` <br /> W Yosemite Avenue ; <br /> SITE ADDRESS 3221 _ bee 16211 5th Street <br /> Sbeet Number StrN <br /> HOME Or MAILING ADDRESS (If DWerent from Site Address) eet Sbeet Number ZIP <br /> STATE <br /> CIT, LAND USE APPLICATION S <br /> Enr. APNn PA-06-519 <br /> PHONE t 241-280-02BOS DISTRICT LOCATION CODE <br /> „ <br /> Exr. '{J "l <br /> PHONE#2 <br /> ( ) CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK N BILLING� D2 RE9S� <br /> REQUESTOR )f Rosu E <br /> PHONE# <br /> BUSINESS NAME FAX# <br /> HOME Or MAILING ADDRESS ( ) <br /> STATE ZIP <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent Of same, <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> acknowledge that all Site and/or 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ATE and F L laws. 2�1910 <br /> p/ <br /> APPLICANT'S SIGNATURE: DATE: //! 7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAG OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY pro 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. ENT <br /> TYPE OF SERVICE REQUESTED: Soil Suitability/ Nitrate Loading Study REC <br /> COMMENTS: 3 19%t, - <br /> X/ ICOUN-fy <br /> �� HEJ>i-TH DEPA�M <br /> APPROVED BY: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> l <br /> atJ 4S EMPLO YEE#: DATE: <br /> Date Service CO pleted (if already completed . <br /> Fee Amount: I Fir. <br /> r <br /> `><7!S�— Amount Paid OZ <br /> Payment Type {f I{7.$: (]0 Payment Date _ <br /> 1- Invoice# /9 0 <br /> l ( <br /> EHD 48-01-025 Check* �Received By: <br /> REVISED 6-5-02 <br /> SERVICE REQUEST FORM <br />