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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5,2007iD/� <br /> OWNER/ PERATOR <br /> ki�n 1 �� <br /> CHECK if BILLING ADDRESS� <br /> FACILITY NAME T1 ef- \ 'p— <br /> SITE ADDRESS 11075 W L-CZ'( C- V\ Zc1 l`/-G,C I.- I53Oy <br /> Street Number Direction Street Name cityZi Catle <br /> HOME or MAILING ADDRESS (If Different ite Address) /C/QD C�tn/ C..I,f f <br /> 4,- <br /> OO/Street Number Street Name I <br /> CITYII��� SCA S 3 <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> (205) %3'3 377) 212 I'1 tin Z )°k- I Z I!) <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> 32 0 3 0 5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' CHECK If BILLING ADDRESS <br /> BUsINEss NAME PHONE# ear. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 assoclated 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,4d FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: / HCl <br /> PROPERTY I BUSINESS OWNER IC, OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is n0 the BALING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: SS RE <br /> COMMENTS. NOV <br /> �Ital/ Y 18201 <br /> k <br /> w v SAENVjOA <br /> IQU/ryCOIJ <br /> I IlHEALTH p M T� ry <br /> T <br /> ACCEPTED BY: EMPLOYEE M DATE: / <br /> ASSIGNED TO: EMPLOYEE It: DATE: <br /> Date Service Com leted (if alread completed): SERVICE CODE: — PIE:t9 (g y-- <br /> Fee Amount: Amount Pa' ��UD Payment Date / / <br /> Payment Type Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />