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SAN JOAQU41kNTY ENVIRONMENTAL HEALTI]PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (?#s S4 -1 o n o •�� /l <br /> OWNER I OPERATOR U U L�=\&/L�=l V LI-m L�� <br /> �"� <br /> I ry\ Tv�o 2 h . Ct f� h or CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> IL 11 <br /> SITE ADDRESS .351 t -9etM0."n 12o cL A 0 rj2 l� <br /> Street Number Direction Street Name PER IPSER Zi Code <br /> HOMEor MAILING ADDRESS (If Different from Site Address) <br /> 0 DX Street Number Street Name <br /> CITYSLoDITATE CA zlP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (2oq ) 319 -5 81 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �� go�� S CHECK if BILLING ADDRESS <br /> BUSINESS NAME `,` ao 1_ I 't o i n f �,��/O✓l Inc— PHONE# ExT• <br /> N <br /> W Ic. L3fce 253-:�>�Iq <br /> HOME or MAILING ADDRESS Fax# <br /> )FID (0184-7 (--40 ) 7-53 Zf39g <br /> CITY \rQnCO U\fe-r STATE o i 1 01 <br /> zip q8 bbo <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,STA and FEDERAL laws.. <br /> APPLICANT'S SIGNATURE: +G DATE: FEg 10 , Zoo <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ owky—x— <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: <br /> SEB 1 b 2010 <br /> SAN JOAOVIN COUNv <br /> EN\JIRpEP RTM-NT <br /> HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: (y i EMPLOYEE#: �� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 P I E: Z <br /> Fee Amount: Amount Paid y s _ Paymen Date 2 ' 2-1 0 <br /> Payment Type Invoice# Check# L� S S (o Received By: (Yy� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />