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SAN JOAQUAOUNTY ENVIRONMENTAL HEALTHIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> or0be Z24;L <br /> OWNER/OPERATOR <br /> / /h CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Fly/ it <br /> SITE ADDRESS t— AJ �d e le-- 7-6 11 e Rd e-o4-- <br /> Directl Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) o <br /> 7 O• a9 Street Number F Street Name <br /> CITY � r � / STATE ZIP g <br /> PHONE#1 j EM• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SE]2VICE REQUESTOR <br /> REQUESTOR1�)OL1VI-0 � <br /> R'Lo Li l i, I , - Z b— � I I CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# �• <br /> ��0.f l�s - 719ornC, s cp _ <br /> HOME Or MAILING ADDRESSr� FAX#3l S" >��_ if <br /> 1-3-7 o l f�-1 ( Ao ) y1 VL <br /> CITY & d - yL C-,- STATE C4 ZIP CI'EJ 04/1 <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: <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER El OTHER AUTHORIZED AGENT SrlOe,%-V0611— .�r, flGNT <br /> IfAPPttcANT is not theBlLLiNGPAR proof of authorization to sign is required Title k'ECEwED <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 geslnlpnZ $ <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sttime it is N� <br /> provided to me or my representative. OAQUIN NTA <br /> TYPE OF SERVICE REQUESTED: 1 1�I/1 Pi-S C J L U I�4�C •- // �' S EN�H pEp RTMENT <br /> COMMENTS: C,I Y'0. Lo/ U <br /> l/ 1 JUN 1 6 2008 <br /> ENVIR NIEN'T HEALI <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid '�a� Payment Date Z, 1� 0 �- <br /> Payment Type Invoice# Check# 3Z)7Received By: j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />