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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PA 0 5 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0413.44" - <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> doA.� LP <br /> FACILITY NAME ��t`X.IR-(0✓ti �fA�O/L /�SU}u/WI"t/ OlJkj'� �QUe I/�/m yV1'� <br /> SITE ADDRESS <br /> Street Number I Direction , 1�` Street Name CO,V Z G de ` <br /> HOME or MAILING ADDRESS ,,(�I/f�Diqfff event from Site Address) <br /> Z ZO I A/Z an Street Number Street Name <br /> CITYy �(�l STATE zip <br /> Lock COIL 64 C? <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICTLOCATION CODE <br /> l2D l 51 - LE5z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Dt,L Le <br /> n CHECK If BILLING ADDRESS <br /> BUSINESS NAMEVIJ Po- tUr• S PZrn# 6-`0^ 33-IL <br /> HOME or MAILING ADDRESS FAX'#tel <br /> CITY stlA-toyll zip 01-3-2-11 <br /> BILLING ACKNOWLEDGEbusine o er, 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 Coder,Standards, STATE and FEDERAL laws. FF <br /> APPLICANT'S SIGNATURE: DATE: 1 d 0 - <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: CO nS I t 1*y/��I 0q RECEIVE® <br /> COMMENTS: <br /> SACOUNTY <br /> ENVIRONMENTAL ENVIRONMMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: , l <br /> ASSIGNED TO: t/1� V EMPLOYEE#: 3 DATE: (I a <br /> Date Service Completed (if already completed): SERVICE CODE: (Apt PIE: I n b�j <br /> Fee Amount: 1 G Amount Paid S 2 — Payment Date C 2-, 2,� <br /> Payment Type Invoice# Cheek# ��L Z 'l ° ?� I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />