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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L neARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o x-7712-- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Sr E:t-r Sv N Ems' <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 617C) I M C-�-�+E- <br /> " i Ave, <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> O D e-ST—o CA q S 35-0 <br /> PHONE#1 EXT. APN# I9�1-0 LAND USE APPLICATION# <br /> 1 91 5-77- O 9 -0 3 <br /> _J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -�7 ' <br /> L C S G I—Vi S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> LC gLAL4- I <br /> HOME or MAILING ADDRESS FAx# <br /> 3 V E IS rCITY STATE CA <br /> ZIP q <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that 1 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: !fib• Z_�-O� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN ER ❑ OTHER AUTHORIZED AGENT EO <br /> f.4PPL/C1INT is not the B11 LING 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: PAYM <br /> COMMENTS: <br /> JkJL - 1 2009 <br /> SPINN�RONMp`E SEN <br /> HATH DEPAR <br /> T <br /> ACCEPTED BY: EMPLOYEE#- DATE: <br /> ASSIGNED TO: ) EMPLOYEE#' 6 Zo DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q ( P I E:�d <br /> Fee Amount: 40. Amount Paid � O � � Payment Date _Z11 <br /> O <br /> Payment Type Invoice# Check# DS 33(o L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />