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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEINICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `?'74�(� :1Et)(W(a17A7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L� u4' l'�nxw `� �G("Nt 5 y M �/7-�� - !i1-Jrv'-pL� ""500 (— <br /> SITE ADDRESS ^"SSS 45",3Szi <br /> Street Number Direction Street Na ma city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ezr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS'IS <br /> r�a� <br /> he \ <br /> BUSINESS NAME n PHONE# <br /> EXT. <br /> HOME or MAILING ADDRESS � ` FAX# <br /> �G-. l'�. ( ) 5q5- <br /> CITY <br /> CIS-CITY !t i Qgu STATE LA <br /> 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 or <br /> activitywill be billed to me or my business as identified on this form. <br /> 1 also certifv 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 /> APPLICALVT'S SIGNATURE: C�L _--��� �L— � DATE: 11 <br /> r'? <br /> PROd?ER.Z7•' USINESS OWNER El OPERATOR/DIANAGER ❑ OTHER AUTHORIZED AGENTRL- A,t�,--A* <br /> JfAPPL/CAIVTisnotthe B/LLINGPARTY proofofauthorilalion to sign is required Title <br /> AUTdIO$ 2A' TION TO RELEASE INFORNIATION: When applicable, 1, the owner or operator of the property located at the <br /> above-site"' dress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information I; the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> pim idcd to me of my representative. !!�� ��77 <br /> TYPE OF SERVICE RAE I -E,S,TEDe7�r��A0 e7 LO�t' r�1E d,+t 2 45,t-coDEL SCK <br /> COMMENTS: 0.W 4(/`^'�' M �N^bl I ./fr ) r L II Qes•Q REC <br /> EIVItU <br /> Q,�-pj.1t rr!!'`nn''��• Q 3oo��P"' ( 31n ��,,,, JAN - 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: VST EMPLOYEE#: ®9J-� A DATE: �. <br /> ASSIGNED TO: EMPLOYEE#: �3 DATE: s !/ <br /> Date Service Completed (if already completed): SERVICECODE: SZ-� PIE: (�•Z <br /> Fee Amount: flO Amount Paid a — Payment Date / 5 <br /> Payment Type Invoice# Check# fieclved By: <br /> EHD 48-02-025 SR FORM/(Golden Rod) <br /> REVISED 1111712003 tl-1*1 & 01 <br />