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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property o FACILITY ID# SERVICE REQUEST# <br /> FlOod aL(eta <br /> OWNER/OPERATOR <br /> OZ CNEcir U BauNG AneREss <br /> Facanr NAME ^ 'S /i ) <br /> SITE ADDRESS1A) I5 . 7th 5T, <br /> StreetNamher <br /> HONE or NIADINOpt DiDetent from Site Address) <br /> Street Nomher seeet • <br /> m 1 STATEMQAIC- tU CR Lr 526- <br /> PWNE#1 �• APIA LAND USEAPPLN:ATION# J <br /> ) 012 32 <br /> PNONEN _ OLT .. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR // <br /> CNECR NBNLNG ADDRE55❑ <br /> BUsimss NAME 4 ' S ry .. PNDNE# �'- <br /> fious,e— � 2- <br /> Norm <br /> Norm or MAatNo ADMEss r . Fax# <br /> i33 (� ( ) <br /> Crry &—sip STATE C ZiP 5 35 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, <br /> admowledge that all site and/or project specific ENMONMENTAL 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 0rdlmmce Codes,Standards.STATE and FED&iAr,laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BMW=OWNERO OPERATOR/MANAGER RL OrmnAUTHORMMAGENTO <br /> IfAPPuc wl•is not the Bu t-mroPaRrr.proof of dWkorka ian 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 ENvIRONM ENTAL HEALTH DEPARTMENT as soon es it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERvtcE REQUESTED: PA <br /> Co"Bi s: E�EIVEiD <br /> JUN 12 1010 <br /> SAN <br /> JOAQUIN CCU <br /> HEAL 0NMENT N 7 y <br /> AccEPTED BY: —L ENPLOYEE9: DatE: ENT <br /> AssaRNEDTo: v, !>` ��J EMPLOYEE#: DATE: <br /> Date Service Completed fd already completed): SERvIDE CODE 523 PIE: <br /> Fee Amount 1�1J Amount Paid Payment Date I <br /> Payment Type Invoice# lCheck# rqed By: <br /> END 48-02.02.5 SR FORM(Golden Rod) <br /> REVISED 11/172003 ' <br />