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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATJOR n <br /> Le a,,- N of ma-q 4A U CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 3 ` ` Street Number I Direction C , `Stre fNaohe "' EsbkI 6(k ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) C <br /> I I C � D`"I <br /> Street Number Vv Street Name <br /> CITY 1� � STATEZIP <br /> PHONE#1 b ExT• APN# LAND USE APPLICATION# <br /> (qb� ) l9b - s i 59 '�o `� 1 - DOD l <br /> PHONE 2 ExT• BOS DISTRICT LOCATION CODE <br /> G ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# ExT. <br /> K�evti u I fi LC I� 0 a - 5�— <br /> HOME or MAILING ADDRESd FAX# <br /> 3609 W 104 ( <br /> CITY S(,ltr0 <br /> /14 <br /> n n 1-t_ STATE A zip <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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT a EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �� �(� �)/', <br /> PROPERTY/BUSINESS OWNER❑ ERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT rfShI,t I-lu2 <br /> If APPLICANT is not the L G 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. f / <br /> TYPE OF SERVICE REQUESTED: TCom. JUJ%(,�✓ �•_ R �� <br /> COMMENTS: <br /> le-J <br /> l� " �00./ / Q EoQVaUtN�c 0 <br /> nOD <br /> S ?? <br /> N�THRavRcq1V ' <br /> ACCEPTED BY: EMPLOYEE#: U DATE: / Z-0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z3 P/E: v u <br /> Fee Amount* 7i Amount Paid ,�Lb Payment Date I (� <br /> Payment Tye Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />