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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3�akE 4 oumGj)- <br /> OW NER I OPERATOR CNECKII BILUNO ADDRESS <br /> R STR//�9. R6-vAloSA <br /> FALIUrY NAME C19fLK/6--1Z sc0.16-- <br /> t3A �R <br /> SREADDRESS 3yy ! <br /> /� CAL/r`ORn//f} ST LO/D l 9S2E/� <br /> Stroet Number Diro Ion Im Nema CI ZI afe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3zy Al, CAI-1 <br /> Slnel Number Neme <br /> CRY Lor <br /> / STATE r N ZIPls' 2 Vo <br /> PHONEN't �• APN# LAND USE APPUOATION A / <br /> GD5) bog-o//q <br /> PHONE#2 Esr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HOME or MAIUNO ADDRESS FAX# <br /> ( 1 <br /> CITY STATE AP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 will) 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 /> i `D ZS Z� <br /> APPLICANT'S SIGNATURE: ljfiti 1 - �17[fJ Dere; <br /> PROPERTY I D USINESS OWN E)U=1� OPEIUTOR/NIANAGER ❑ 0TIIERAl1T11n RIZEDACENT0 <br /> IfARPL1CANT is not the BIL/ATG PARTY proofofauthorliation to sign 1s required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at die <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirommentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the at(irpsil is <br /> provided to me or my representative. <br /> TYPE OF SERVILE REDUESTED: D <br /> COMMENTS: I'u30 ?0 <br /> SAN,/ENV0gQUI C 2 <br /> HEq TH Q p RN A �Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7/51) <br /> y <br /> ASSIGNED TO: ''I '7. . EMPLOYEE#: DATE: JL9 yZ <br /> Date Service Completed (if already completed): SERYICECOOE: "� P1 E: '(po2 <br /> Fee Amount: Amount Pal /5-6,ob Payment Date 730 7 <br /> Payment Type , Invoice# Check# $gZJ 3 Reeel dBy: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11117t2OD3 <br />