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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00U� � 0 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> -�- i <br /> FACILITY NAME hm <br /> SITE ADDRESS (elv 1. •� A.rt_r �yQ tj' � <br /> Street Number DIr c ion Ft 1. SCreeet Name CityZip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number $treatN m <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (.&A ) 9B.075ca 0000N 0 i� <br /> PHONE#2 En. BOS DISTRICT <br /> 11 O0-4 LOCATION CAO9F <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> jLOD Y / f.Lp CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT <br /> AP( 20 5'"►T•44v&( <br /> HOME Or MAILING ADDRESS FAX# <br /> O (ZOT ) 571-41L(3 <br /> CITY L A._ STATE CIA ZIP 'es-ss-co ScD <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 STATE l EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: lzmrL( <br /> PROPERTY/BUSINESS OWNER❑ OPE 'OB/MANAGER 01'HENAmHORIZEDAGENTT9 APuaffjcZ:: <br /> If APPLICANT is not the BR:7.YNG PAR Tr 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 SaAme time it is <br /> provided to me or my representative. ry <br /> TYPE OF SERVICE REQUESTED: -pl iI <br /> COMMENTS: <br /> Pox its P� �r��. SqN APR 26 ?Opl <br /> NEA TN�Q ARTMENT <br /> ACCEPTED BY: Cft�fPi.1r.�.S LO EMPLOYEE#: DATE: <br /> ASSIGNED TO: , ^ _. EMPLOYEE#: DATE: <br /> Date Service Completed `('if`already completed): SERVICE CODE: �- PIE: Q <br /> Fee Amount: +H,5(0._ Amount PaidPayment Date -+ 1 <br /> Payment Type Invoice# Check# rZ Receiv d Ety: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED II/1712003 <br />