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SAN JOAQI►trV COUNTY ENVIRONMENTAL HEALTH OPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS El <br /> FACILITY NAME L A LA P F J CIrl—7 <br /> SITE ADDRESS ­72j�D � S I Ca L% an v, I 1 -,4 �'?� {�i� q 5 Zl: <br /> Street Number I Direction Street Name city Zlo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1--7--7 I 1 e Y, C✓-ee K �1 2 <br /> Street Number Street Name <br /> CITY \ ^ STATE CA <br /> ZIP ^1\� <br /> PHONE#1 `-,✓ ` ExT. APN# LAND USE APPLICATION# `U <br /> dM 3kp 1 �l k(o Ce l_P <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Gt r N\,A �r c CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME L V4 ��� 1� �l°I PON # ,EXT' <br /> i - I <br /> HOME Or MAILING ADDRESS ` FAX# <br /> CITY S 1 \ ^ STATE &/\ ZIP tt '520—�— <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 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 SIGNAT RE: tX � u C17 Gi r-Of DATE: <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. I p <br /> TYPE OF SERVICE REQUESTED: / � �� 1� I,CU VS e �1� <br /> COMMENTS: <br /> 0� OVA_W-vr�IAA W s - 4N V <br /> 8 <br /> y�qj ZY U/NC 20, <br /> yFpq� 041, <br /> N��N <br /> ACCEPTED BY: V�V f EMPLOYEE DATE: T <br /> ASSIGNED TO: rn . �I ut��SL iti1.L EMPLOYEE M DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: Q(a ( PIE: LP�J <br /> Fee Amount: I C�Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />