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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LikaouR sVo'f <br /> OWNER/OPERATOR ` <br /> Pv� \ SSU CHECK If BILLINGAODRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS IS Lo,ke vio0 yy\.-u L-o I) \ S 21'1 Z <br /> Street Number Direction Street Name Ci Zi Code <br /> l HOME Or MAILING ADDRESS (if Different from Site Address) �2 t -} I OOE*) ONR K L- <br /> -N <br /> \ - Street Number Street Name <br /> CITY STATE ZIP�� PHONE#1 ET- 7N# LAND USE APPLICATION# <br /> (a�w q �n - 3e� 1 LZ35 `IGG <br /> PHONE#2 ExT. BOS DIS IICCT t LOCA®�COOE <br /> ( ) O <br /> L4 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E'. <br /> G 00 ^ 7 It <br /> HOME Or MAILING ADDRESS FA%# <br /> K ( ) <br /> CITY _S TATE ZIP 53V-� <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 Or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 01C <br /> -laws. <br /> APPLICANT'S SIGNATURE: DATE: 1127- La O/d' <br /> f <br /> PROPERTY/BUSINESS OWNER o,,g OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: )60:2 FtlodCms,14 Qt d ylq,J h C�'lWt .p <br /> COMMENTS: <br /> z <br /> HR NM <br /> ACCEPTED BY: -- I EMPLOYEE O DATE: I .aa <br /> ASSIGNED TO: g , �4y✓t Z EMPLOYEE#: 8' I <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C)(n I PIE: <br /> Fee Amount: Amount P ' S"� 0E) Payment Date <br /> Payment Type Invoice# Check# Recelied By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />