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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &PPIcty ,�� 00 SLI <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME K <br /> SITEADDRESS 260a S B/RD ROAD TTACy 5304 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7A r DFLAN E�/A VC <br /> Street Number Street Nam/e <br /> CITY STATE ZIP <br /> DPUANDO FL 3a o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (.709) �a7- G�o9 ass- opo- 64 FA- t6 00-23 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I 0 t4 G >E5 CHECK if BILLING ADDRESS❑ <br /> E <br /> BUSINESS NAME PHONE# EXT, <br /> 0[4r--6tq.F—VC 0 u a?O O <br /> HOME or MAILING ADDRESS FAX# <br /> 0 3 ( ) <br /> CITY Lock— STATE ZIP 53 / <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 ENVIRONNIENTAr.HF.ALTH DEPARTNIEN'r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance(.'odes,Slandarcfv 'ATF an F.RAL.laws. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> PROPERTY/BDst\Ess OwNF.R❑ OPERATOR/MANAGER ❑ OTHER Al"rHORIl,E:D AGF.\"I'a <br /> 1f APPL/CA\T is not llre BILLA.;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 ENVIRONNIENTAL HE."ALT}I 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: Su R C,orCE N D G!6 u f A p HYMEN <br /> COMMENTS: MICEWED <br /> FEB 2 4 20M <br /> SAN JOAQUIN COU TY <br /> ENVIRONMENTAL <br /> HEALTH EPARTM NT <br /> ACCEPTED BY: J-} EMPLOYEE M DATE: �f� <br /> ASSIGNED TO: ` EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: P I E. <br /> Fee Amount: Amount Paid ! 3 O Payment Date LD <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />