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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST c— <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ro02SJ; Sr2oo1L19to3 <br /> OWNER I OPERATOR to <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 6 I Oo(I l.-.. 0 M i U 1 <br /> SITE ADDRESS F) 1 -1 ! V`VIJ^ � S 52c�lp <br /> Street Number Direction Street Name city Zip Code <br /> HOME Of MAILING ADDRESS (If Different from Site Address) -IQ <br /> V Street Number l e v r a lgtreet Name <br /> CITY ` I O D STATE ZIP <br /> PHONE#1 .Jl i En. APN# LAND USE APPLICATION fl <br /> ( ?(-I G66 TT 2. <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> r o n P.`�Pl 0 CHECK If BILLING ADDRES <br /> BUSINESS NAME . 1; PHONE# EXT. <br /> HOME or MAILING ADDRESS , V r FAX# <br /> X32 ler ao�a 4 ( ) <br /> CITY t O O N CA 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 Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: P P p DATE: ✓�— ' 4I – 201 2_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> /f APPLICANT is not the BiLLiNC PARTY proof of authorization to sign is required Titte <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 availablle 7> 3hesxne time it is <br /> provided to me or my representative. ^ , AA&r <br /> �� <br /> TYPE OF SERVICE REQUESTED: PO VQ k i� C AASK. <br /> COMMENTS: FEB 1 <br /> Cln D� l�VJ��SI.�.I.p <br /> 2W— <br /> SAN JOAQUIN CWt41'Y <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: IM, EMPLOYEE#: DATE: <br /> ASSIGNED TO: VL EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: IDLO <br /> P �O <br /> Fee Amount: Amount Paid #/5 _ Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />