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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> X77;c 3(d� <br /> OWNER/OPERATOR <br /> DP • 1 CHECK if BILLING ADDRESS <br /> FACILITY NAME SSvtreaKt fa I`oa Yo <br /> (e) <br /> SITE ADDRESS '-200 -PorT <br /> 1 (�� 5C`�ode/�Number DU. n Street Name <br /> no <br /> HOME Or oMAILING ADDRESS (If Different from Site Address) <br /> D �p Ct-Lc,- 1 Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EX. APN# LAND USE APPLICATION# <br /> h-\o0 LA'L3 - <br /> P/HO�NE#2 EXT. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> D f1y'Lg CHECK It BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# Ex ' <br /> v <br /> (2H(1 ) 'i — 132 <br /> HOME or MAILING ADDRESS ,, / FAX# <br /> CITY <br /> r <br /> S-- SE zip �c <br /> L t G <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: n-� --��� DATE: of�m 6r L 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPvcANT is not the BtLLtNG PARTY proof of authorization to sign 1s 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. FIXYMENT <br /> TYPE OF SERVICE REQUESTED: lCOOSO lfahtd RECEIVED <br /> COMMENTS: <br /> MAY 0 6 2011 <br /> ENJOAQUIN VIRONMENTALTM <br /> ,t .HEALTH DEPARTMENT <br /> ACCEPTED BY: I /1� EMPLOYEE DATE; lt, �f_ <br /> ASSIGNED TO: V` EMPLOYEE#: DATE: v21 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: /03 <br /> Fee Amou t: .OV Amount Paid — Payment Date 5 z/ <br /> Payment Type v Invoice# Check#I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �In o�2f ^aL11 <br /> 1� >w � <br />