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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R L rGF-5TIAL <br /> OWNER I OPERATOR <br /> r ,F� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> X0/2 <br /> ,�/ ��G k 7-0,/4,25 <br /> SITE ADDRESS y 9SToc kion/ gsalz-9338 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (&y ) 931- ss 063—'200- ow PA - /o0o�7o� s <br /> PHONE#2 EXT, BOS DISTRICT [LEOCA;1iI N CODE <br /> (zo ) 91)� -1450 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> %lDl// �1� CHECK If BILLING ADDRESS <br /> BUSINESS NAME (� � PHONE# EXT. <br /> 4rlfFSAIE C:WJal T/n1C (xo ) _ D <br /> HOME or MAILING ADDRESS <br /> 5,-2X <br /> 3 774 <br /> FAX# <br /> cZV1 -z 5-M <br /> CITY / dG STATE �-�t ZIP p�3 / <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 ebarges 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: //- a /0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATORi4�I <br /> I ANAGER ❑ OTHER AUTHORIZED AGENT 27 <br /> If APPLICANT is not the BILLING PARTY,proof of uthoriztztivn 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: 50/1- u /TA 0/G/T S Z:Ld D'V R45VI F� PAYMENT <br /> COMMENTS: / '41V RECEIVED <br /> /L&&Zha0,CJJNOV 2 2 2010 <br /> fJ 6, G /IG SAN JOAQUIN COUNTY <br /> HE ENVIRON <br /> DE DEPARTMENT <br /> ACCEPTED BY: - 9 EMPLOYEE M G DATE: n <br /> ASSIGNED TO: `� j[�� EMPLOYEE#: G DATE: r 6 <br /> Date Service Completed (if already completed):: �� SERVICE CODE. ZZ PI L 2(00/ <br /> Fee Amount: �)—L ,5-o Amount Paid 0 Payment Date (I 2,q( <br /> Payment Type Invoice# Check# S 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117=03 <br />