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SAN JOAQIOCOUNTY ENVIRONMENTAL HEALTSEPARTM <br /> SERVICE REQUEST w' FILE Con <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6DF O S 64VO sy7.3a <br /> OWNER/OPERATOR ^ haran CHECK if BILLING ADDRESS E] <br /> FACILITY NAME Trac- T-ruc'K <br /> SITE ADDRESS 3q 4 U N T- <br /> • - ra 31 vcL, ��G <br /> Number Direction Street Name Ci 053cer-T e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZCT 212 - 2-0 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> MeUG6eu yd <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEftFE)L PHON EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> F.b• Sox 551 ) 194 f <br /> CITY / I/ trISTATE CA <br /> ZIP 2L5 5 <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,Standards STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: L143- 10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a <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: S ( PAY Ep <br /> COMMENTS: <br /> ApR 13 2010 <br /> OAQUIN COUNN <br /> SANJ HEEANV DEP RwENT <br /> ACCEPTEDEMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alre6kcompleted): SERVICE CODE: PIE: <br /> Fee Amount: Amoun Paid 3 LF 5111 Vic 421� (D-0 I Payment Date l L3 J u <br /> Payment Type Invoice# Check# 1--13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />