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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME `F I9,Eo <br /> SITE ADDRESS `"l�S N l7F_ 5-T <br /> Street Number DI I -i n Street Name <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 02-4.3 <br /> Street Number Street Name <br /> CITY� � STATE � ZIP ,t�'•7/� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# _ <br /> (?AI ) L14 Zl L4/0 <br /> [PHONE#T ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR /� <br /> DNJ��) / /6 - (a CHECK if BILLING ADDRESS <br /> BUSINESS NAME I� LM(J(L(LVJ� 07-7-11 0V/E-� PHONE# <br /> �LIV1 Z qZ- 4116 S <br /> HOME or MAILING ADDRESS r// i--- <br /> FAX# <br /> FAVLSQL L/i ( ) <br /> CITY sa C&-IGfry STATE j/— zip 66Z,0 <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,S FEDERAL law . / <br /> APPLICANT'S SIGNATURE: DATE: l� b <br /> PROPERTY/BUSINESS OWNER❑ BATOR/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 <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. AA <br /> TYPE OF SERVICE REQUESTED: Nr <br /> COMMENTS: V <br /> sq,v�UN 6 ?019 <br /> Her f?o 0UN7j, <br /> H 10EPgRNTAC <br /> ACCEPTED BY: EMPLOYEE#: DATE: s <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> WO 2- <br /> FeeAmount: c�Z o Amount Paid �� Payment Date <br /> Payment Type Invoice# Check# �( 7 Re' c6ive6 By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />