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• SAN JOAQ*OUNTY ENVIRONMENTAL HEALUWARTM ENT <br /> SERVICE REQUEST <br /> Type of Business or Property W-" ,y FACILITY ID# SERVICE REQUEST# <br /> Sae- - 6AS &Sw& 3.7 d-7 Ste,o s L, 3-Y-7 <br /> OWNER/OPERATOR <br /> s,,., --WA�Ou �� � SSS ����� CHECK if BILLINGADORESS❑ <br /> FACILrrY NAME <br /> 5 _'TVu l [°oLcnzy •— S szsPF`5 c€t_�2 <br /> SITE ADDRESS � L`AM� �5� <br /> '1©t�p M�LI+AEL CPnJI.aS e LSI D <br /> Street Number Direcft Name cilty. ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) N)A _ <br /> v l/R — Street Number Street Name <br /> CITYKASTATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-2A ) 3 y-g x) <br /> PHONE#2 ECT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> S>rwF- — W 34-0CIO <br /> HOME Or MAILING ADDRESS FAX# <br /> 2.3-70 IY1 A G Gm ,1C:_ ��- (269) 36`7 —5424- <br /> CITY L-OD:T- STATE (1fl ZIP Iq 5740 <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 <br /> or 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,Standard TE d FEDERAL laws. <br /> APPLICANT'S SIGNADATE:/0Ll2-3 j9 <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER OTHER AUTHORIZED AGENT M- 6&JWAC=P— ;:- {L- 5�C <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 <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: <br /> COMMENTS: C4pl.-y W wn{ POSE YT r V lZ u G p_"r .tjj A-C eoAQ RENT <br /> �tT�+ X�r. 00-'Afa- VM 2-01 11 EIVED <br /> JAN 2 6 2009 <br /> SAN—JOAQUIN <br /> ACCEPTED BY: � t U'�I ' - EMPLOYEE#: Ci � Z X7}21 <br /> ASSIGNED TO: C.N . EMPLOYEE#: s�, DATE: ZL; <br /> Date Service Completed (i already completed): SERVICE CODE: cr PIE: , <br /> Fee Amount: Amount_ Paid Payment Date <br /> � 142 <br /> Payment Type Invoice# Check#c;2 R ceiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />