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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Skoog 3� 38 <br /> OWNER/OPERATOR q Bo. <br /> � 6lt?s'� cJA�l42Y �erdp. �17e3 i7art � CHECKifBILLINGADDRE53❑ <br /> FACILITY NAME <br /> SITE ADDRESS < ,^t, „v„�1V <br /> I J f( Lt✓� <br /> Street Number Diredlon Street ame ST(/ CI ZI Coda <br /> HOME or MAILING ADDRESS <br /> y(if <br /> 'Different from Site Address) H 1 `TcJ -n Q �. 1., -b p o c(-p QjT-7 GC�� <br /> P(� • 0 . BOX 9529 � r '�����street Number Street Name <br /> CITY � T 0 G 1<7 <br /> T�N c o-L STATE ZIP "76" ^ O6� <br /> PHONE#1 Eir. APN# LAND USE APPLICATION# <br /> a( 7a6) 712- - /543 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �s ' <br /> d ^ Q e d PV f-e Y If e-^r 0� �j�j )3A Y W(%G:rHECK If BILLING ADDRESS <br /> BUSINESS NAME C^! A� R t � ,A G RO c 4E A y I I C1 6 (�_ 9 5� 3 <br /> HOME Or MAI G ADDRESSFAX# <br /> rJr` Q3©xA` 0539 ( ) <br /> CITY � 6 V C KT 0,V CA <br /> 1 STATE ZIP <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: J <br /> PROPERTY/BUSINESS OWNER❑ OPERATORI GER rHERA THORIZED AGENT <br /> YAPPLIcANT Ls not the BI <br /> L <br /> L <br /> (NGPARTY 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 environmentaVsite 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. P <br /> TYPE OF SERVICE REQUESTED: <br /> p ���7 Ce. <br /> COMMENTS: -{�"A /C V !l 1 u tR NICs MAR 112011 <br /> 1 W l J NMFNTUNry <br /> •r7 �'�1RTjy NT <br /> ACCEPTED BY: EMPLOYEEM DATE: 3 7'J 2( <br /> ASSIGNED TO: /I. V� D EMPLOYEE#: 1 U�l - DATE: 2 —�— 1 12,1' <br /> Date Service Completed (if already completed): SERVICE CODE: D r P I <br /> Fee Amount: Amount Paid �!—a Payment Date 2Z <br /> Payment Type L 19 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003. <br />