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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PIZ D 5 q 7Z73 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR `1 <br /> f Ino hjl''L-thdPT CHECK if BILLING ADDRESS <br /> FACILITY NAME EL ( V Q�U 1u G J `pf -F� UU <br /> SITE ADDRESS '2 O �l S (411 t-O/✓1 t 4 S� pC K-TC�f� <br /> Streal Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S. cJQ Lf CI YY'`P ht d <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CR 615Z4u <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> (ql(,,) -n3y <br /> PHONE#2 En• BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR `, 1 <br /> fl,4v1 <br /> � � �\v� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 111�����` PHONE# Ex*. <br /> L C'lvuclu lu Gnu �% 3 ()- 666S <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 Coder,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I ` DATE: 1 I I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is no[the BILL/NGPARTY proofofauthoriZation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the prope �}gcated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen / I �t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atirgeCis <br /> provided to me or my representative. II VVVVVVED <br /> TYPE OF SERVICE REQUESTED: StI D 8 <br /> COMMENTS: HE LTVIRONME OIJNn <br /> H�EAAR M NT <br /> ( o-3 I q lum I 10 06 Colon <br /> ACCEPTED BY: C4 A r EMPLOYEE : b DATE: I 1'2A/ <br /> ASSIGNED TO: Irl 0 EMPLOYEE#: / DATE: '()JJ2/ <br /> Date Service Completed (if already completed): SERVICE CODE: Ale 11 E: (J <br /> Fee Amount: 'Q Amount Pakpl5,2O Payment Date /2 2/ <br /> Payment Type Vi6'-— Invoice# Check# ( d�UO� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />