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SAN JOASN COUNTY ENVIRONMENTAL HEALAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS 0 <br />FACILITY ID # <br />SERVICE REQUEST # <br />n <br />71AUN5fE/L l9tdCt55;T AG.1� <br />F <br />L <br />3 ?'At,- -00 j T <br />S F- 00"-7-7 <br />OWNER / OPERATOR ex", 4.a I t%!q I Ii!� <br />uSA �,,R 07E BF C,9-rF,9"i 4 J�a L� C� ✓itis CHECK if BILLING ADDRESS <br />(/��V T J <br />FACILITY NAME ^ CNTI'r'/'t L 0"61 <br />t, <br />vJAS T& <br />SITE ADDRESS <br />ASSIGNED TO: 0447W I,'4 <br />64i -r- ,rU"CJL F,rJ <br />EMPLOYEE #: 41d 28( 3 <br />DATE: L41' —11� 7 <br />1$33 Oar, Street Number <br />DirectionStreet <br />Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) <br />Payment Date <br />Q boy 2q } d ( <br />Street Number <br />Street Name <br />CITY <br />Lodi <br />STATE ZIP <br />C g67'4 41), <br />PHONE #1 EXT. <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 4-e� <br />CHECK if BILLING ADDRESS 0 <br />BUSINESS NAMEP# <br />J �Dy <br />EXT. <br />3— <br />HOME or MAILING ADDRESS <br />©D d-FA7X <br />4%�� <br />"'0"4, <br />M <br />CITY <br />STATE /,f ZIP ; 5:�) yt�) <br />BILLING ACKNOWLEDGEMENT: 1, 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, ST E and F 'DERAL laws. <br />APPLICANT'S SIGNATURE: DATE:�11� 7- <br />]PROPERTY/ BUSINESS OWNER❑ PERATOR / MANAGER OTHER AUTHORIZED AGENT 13 V,j� MOV ie`l�Ngl9�L <br />IJ APDL ICAAT is not the BILLING PARrr, 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 me time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />J �Dy <br />COMMENTS: L <br />fLf <br />�% , <br />—142 ,, F-�•/% ^ �P. C ti <br />4%�� <br />"'0"4, <br />M <br />ACCEPTED BY:y� (�' L(� j 3 ®� ��I �� <br />EMPLOYEE #: <br />DATE:j� <br />ASSIGNED TO: 0447W I,'4 <br />J 1 j3 t j �� <br />EMPLOYEE #: 41d 28( 3 <br />DATE: L41' —11� 7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ��� <br />P I E: yl/o S <br />Fee Amount: S`6 <br />Amount Pai � � �)d <br />Payment Date <br />Z <br />Payment Type 5 <br />Invoice # 29 ,, <br />Ch # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />