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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (Or re �� — S� oosq oo0 l <br /> OWNER I OPERATOR <br /> �S �DLn 1! CHECK If BILLING ADDRESS® <br /> FACILITY NAME Ih1 <br /> r�erIS__ <br /> SITE ADDRESS � I 'I AI SLAT/ S` �LI(qGl T /SL �O <br /> Street Number Dlrec[lon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Se Ir Street Number f A� Street Name Gt <br /> CITY 1 1 J IL S(_7'�P 55 <br /> PHONE#t C'YCl Em APN# LAND USE APPLICATION# <br /> (ZO ) 2 -9 — LILIyq <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -p <br /> fill) W,���—ary CHECK If BILLING ADDRESS <br /> BUSINESS NAMEi PHONE# ExT. <br /> ZIA � ul i DC91 pi Grvu 2q I 478- YO l3 <br /> HOME Or MAILING ADDRESS J aFAX# <br /> '7677 N P4rsk�•• RV e (Zoe ) 478— 02I <br /> CITY0.'I h„ (ATE ZIP p52-07 <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 applicatio d th he to b erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT nd E L <br /> APPLICANT'S SIGNATURE: DATE: / Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I.fAPPLICANTis not the BELLING 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. <br /> ir <br /> TYPE OF SERVICE REQUESTED: ,fit f�j •� � �N <br /> COMMENTS: �( —T-�* V✓l <br /> d � tgN��C 1 g <br /> $ ?0?1 <br /> NE9CTN pEPM�M O <br /> ACCEPTED BY: f, G EMPLOYEE#: DATE: 7-2 <br /> ASSIGNED TO: (i�-- w`\iAQ EMPLOYEE#: DATE: 2 / ^2( <br /> Date Service Completed(if—alllready completed): SERVICE CODE: 9: .y? PIE: <br /> f <br /> Fee Amount: _ Amount Paid ` / Payment Date 2 Z <br /> Payment Type Invoice# 2 1 2l J�2 Rece)ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />