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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> INNER OPERATOR CHECK If BILLING ADDRESS❑LTW <br /> vv' \ <br /> FACILITY NAME r/� I va l l ( C y U. Y ` I <br /> SITE ADDRESS 5 /'u I I _I 5 �v L LV p� <br /> 25 siroNxumMr D l� (� <br /> HOME,gr MAILING ADDRESS (N DNferem from Site Address) <br /> i 0 . 0y l O St"tNurnber <br /> CITY STATE I ZIP qS 2-3 <br /> PHDNE#t E T- APN A LAND USE APPLICATION# <br /> (IN) ) UD - 4J q <br /> PHONE#I En. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f CHECK N BILLING ADDRESS❑ <br /> BUSINEss NAME En <br /> Do( cezaa�. P 4# (PD3 -� (�rl. <br /> HOME or MAILING ADDRESSPo i7 ©x I �� ( <br /> U FAX III ) <br /> CITY n ,1Y rJ STATE CA LP I 3 <br /> JILLIIVG ACICNOWL•EDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> Iclmowledge that all site and/or project specific ENvIRoNmE TTAL 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 1 have prepared this ap cation and that the work to be performed will be done in accordance with all SAN JoAQtnN <br /> COUNTY Ordinance Codes,Standards,Sy TE and FF. llaws.. , 1 <br /> APPLICANT'S SIGNATURE: XJ(Nyi' lit/ VI/U�V DATE: ^ l 7-2- <br /> PROPERTY/Bus <br /> ZPROPERTY/BUs %Es.SOWNERd OPERATOR/MANAGER ❑ OTHERAUTnoniz DAGENr❑ <br /> IjAPPL/CANr is not the B/LLP/G PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, t, 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 /> TYPE OF SERVICE REQUESTED: <br /> ComaExrs: .0 U'6 <br /> SAN JOAQUIN COU <br /> 2�t <br /> HEMh 01V1) ME Z NT <br /> ACCEPTED BY: EMPLOYEE#: DATE:r6 r0 G <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> late Service Completed (H already completed): SERVICE CODE: PIE: <br /> Fee Amount Amount Paid 1�! Payment Date S jq5 22 <br /> Payment Type Invoice# Cheek# Received By: <br /> EHD 5 SR FORM(Golden Rod) <br /> REVISEDSED 11/17/772003 <br /> QP�05L1�`�12 <br />