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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .S�Qoo�3,5� <br /> OWNER/OPERATOR <br /> PETr,Q CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS q/3SS-7 .S �i�EDE.e/« GG VES /p0� '7 SJ�lotrri <br /> Street Number Directlon Street Name -/ Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �go su/v 11A'Q'JFy �UQT <br /> Street Number Street Name <br /> CITY / STATE 5.A ZIP GfS3�.b <br /> PHONE#1 E-* APN# LAND USE APPPLIPLICAnON# <br /> (a0I '/�O/- `1/93 ?478 PA- fl - /l)/ <br /> PHONE#2 EXT. BOS DISTRICTS LOCATJpN�00E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> 4M/er t/" ,F�4E� <br /> N 7 CHECK If BILLING ADDRESS <br /> BUSINESS NAME �uAP _ PH E 33y- 66/3 �`T <br /> HOME or MAILING ADDRESS �D pox 'K/.6O (A9�FAx 111 33#— 10 7s;?3 <br /> CITY O STATE to ZIP �S,7tJ/ <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 with this project or <br /> 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 f work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL 'aWS. <br /> APPLICANT'S SIGNATURE: DATE.:,/ 7 �/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M ER ❑ OTHER AUTHORIZED AGENT L7 F <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 enviromnental/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: ✓p er Ems Vol@ <br /> ;oeuE1S: RECEIVED _ SEPI 7 2011 <br /> SEP 2 / ZO�� ERMRONMENTALHEALIH <br /> SAN JOAQUIN CC JKTy PERMIDSERVICES <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B EMPLOYEE#: �"'\ � DATE: <br /> ASSIGNED TO: EMPLOYEE#: PO.5 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE:a�O� <br /> Fee Amount: Odl Amount Paid ��? j`-'• Payment Date <br /> Payment Type _ Invoice# Check# �iy� Receive y. <br /> EHD 48-42-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />