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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business c-Properl4 FACILITY ID# ----J- SERVICE REQUEST# <br /> SILO D Z© S <br /> OWNER I OPERATOR <br /> S /C Lq /, GG S CHECK If BILLING ADDRESS� <br /> FAcILm NAME <br /> SITE ADDRESS /��� <br /> Street Number Direction S[r et Name Lcity Zip Code <br /> HOME or MAILING ADDRESS f Different from Site Address) <br /> ' /'Mi^ Street Number Street Name <br /> CITY STATE ZIP <br /> ad, s 5.2 lit <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> I ) 053-moo-bl /-?V-e�--/yl77-7s <br /> PHONE 92 ExT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r C3� f, S5 V t� �- CHECK If BILLING ADDRESS <br /> Bu ss NAME PHONE# 2 E.T' <br /> ®J 7 _ -5 <br /> HOME or MAILING ADDRESS FAx# <br /> 1 -W Oalc It>---:L (aa ) 5 31 - 23 73 <br /> CITY 1 � (t. STATE CA ZIP �5�Y O <br /> BILLING <br /> OIAACKNOWLEDGEMENT. 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 oI <br /> activity will be billed to me or my business as identified on this fomL <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 FE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAR ❑ OTHER AUTHORIZED AGENT <br /> If APPLicANT is no he 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. <br /> TYPE OF SERVICE REQUESTED: U� yLjs JL RECEIVED <br /> COMMENTS: <br /> CLEC L 0 2006 <br /> /?EPrs t7 l2/rc�c/c� <br /> SANNVIRONMENTAL <br /> HEALTH DEPARTMEI IT <br /> ACCEPTED BY: ,D i EMPLOYEE DATE: /.:a, <br /> ASSIGNED TO: le <br /> �� EMPLOYEE#: 556�L� DATE:1-2 yo 06 <br /> Date Service Completed (if already completed): SERVICE CODE: ( � PIE: / 6 <br /> Fee Amount: sq���, o Amount Paid - C z� Payment Date <br /> Payment Type �. Invoice# Check# „>O Y Z— Received By.Z <br /> EHD 48-02-025 SR FORM(Gotden'Rod) <br /> REVISED 11/17/2003 <br />