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SAN JOAQUIN'60UNTY ENVI`r2ONMtNTAL HEALTH ib, t ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property SERVICE REQUEST# <br /> C,%44-ce IC QN9 PadS2G27 99(� j <br /> OWNER/OPERATORJ <br /> GI rLGfXc 1L _ S roTu s I tO e' MAY 1 4 4-010 CHECK If BILLING ADDRESS <br /> FACILITY NAME ENVIRONMENT HEALTH <br /> CA 2G-a lL. �o2ES I t-/C . <br /> SITE A/DDRESS CIj1/jC1.•1,(31�/L T,C,Itd= L.Alt"1+rc"Or RS330 <br /> I b 4 70Street Number I Direction Street Name I City ZIPCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Ll e� s E. TL1 r J C-0 f J S;i-- <br /> S"et Number Stmt Name <br /> CITY ^-^2®N ^ STATE /1 .n T_ ZIP c : C 7 C1 <br /> PHONE#1 K En. APN# LAND USEAPPLICATION# K•o / <br /> (951 ) 27o-5163 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 6140 -o DI-E CHECK If BILLING ADDRESS <br /> B SIN SSN ME PHONE# Ext. <br /> tjizv re, nJG SIS S-qZ-? <br /> HOME or MAILING ADDRESS FAX# <br /> .20 Lou- AL4%, AU. STS_2<>"? ( ) <br /> CITY V " STATE CA— ZIP Ott 502, <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 /> 1 also certify that I have prepared this application anhat the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and 2E!,AIaws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ♦ J s'Z'9110 <br /> PROPERTY/BUSINESS OWNER❑ ANAGER ❑ OTHER AUTHORIZED AGENT.a:.l OrG a AJT <br /> /fAPPL/CANT is not[h ILLIN ARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: PAYMENT <br /> COMMENTS: <br /> MAY 14 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B EMPLOYEE#: DATE: d <br /> ASSIGNED TO: EMPLOYEE#: -Z3(P� DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE; <br /> Fee Amount: Amount Paid 3LA — Payment Date S11'3l1 O <br /> Payment Type / Invoice# Check# 3 $ Received By: N& <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />