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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FA11 <br /> iILITY, ERVICE REQUEST# <br /> OWNER/'O',AtPERATOR p {�,l (�I `ol d0'�i/QU1T'J� <br /> L-` S- � C— CHECK If BILLING ADDRESSE] <br /> FACILITY NAME <br /> SITE AD1DRES <br /> 13 1 <br /> Street Number Direction C SStFt ame <br /> Lex-1 C. `7 ii Cadeu <br /> HOME or MAILING ADDRESS (H Different from Site Address) LaSPs� I IZ3 <br /> 3DStreet Number Street Name <br /> CITY STATE ZICP pp�� ' <br /> I..4 <br /> PHONE I EI'T• CA APN# TLAND USE APPLICATION# <br /> 1 D <br /> (5�j ) le u S • S2Z9 <br /> PHONE#2 ExT. S DISTRICT LOCATION CODE <br /> ( 7ifil Z)o v i 5th <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTflR p <br /> `, W t"'J CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY <br /> 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 HEALTIi 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z Fr • ZZ <br /> PROPERTY/BusINESs OWNER[3 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IJ'APPLIGI,vT is pat tae BTLI.ING PARTT.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. p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> FFBSA Al 08 O <br /> ly, GTy�PqR OfU, I'Y <br /> ACCEPTED BY: EMPLOYEE#: <br /> DATE: <br /> ASSIGNED TO: 0•,f-� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q P/E: 6 Q <br /> _.-_- Fee Amount:- AmotmtPal <br /> L5, , Payment Date �J'V.L� <br /> Payment Type Invoice# Check# O S / Re ived By: <br /> EHO 48-02-025 E� <br /> REVISED 11/17/2003 ����®y,�� SR FORM(Golden Rod) <br />