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JAN JOAQUIN-LOUNTY LNVIRONMEN'1'ALJUEAL'1'N DEPA i'N1ENT <br /> �- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S(io03o842 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> � L( <br /> FACILITY NAME <br /> SITE ADDRESS J„ r a CO ,-- CQ <br /> Street Number Direction Iv Street Name `kX6i- ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> TI (J71L Street Number Street Name <br /> CITY STATE ZIP <br /> LC �. <br /> PHONE#1 EZ . APN# LAND USE APPLICATION 11 <br /> (q+ ) -(v P ®200-5r 5 <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ����//�� <br /> y y 1 CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME I• PHONE# E. <br /> 1 2'S- Soo <br /> HOME Or MAILING ADDRESS0�W , FA%# <br /> tJJL INLx (qti,) - (.0-8(O-3Sock <br /> CITY L STATE CA 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 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 JOAQufN <br /> COUNTY Ordinance Codes,Standard^,STATE and FEDERAL laws. 30310 <br /> y� / T <br /> APPLICANT'S SIGNATURE: ( DATE. 0103 /V <br /> PROPERTY/BUSINESS OWNER OPERATO /A NAGER ❑ H :AUTHORIZEDAGENT LIO �t_l <br /> If APPLICANT is not the BILLING .proof ofauthorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: d <br /> COMMENTS: �' p PAYMENT <br /> n /S�e► � j ��/r��, RECEIVED <br /> OIL)14�- AUG14ZM2 <br /> f o SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONME%NAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: `L2� DATE: 9 <br /> ASSIGNED TO: EMPLOYEE#: q DATE: U y'J <br /> Date Service Completed already c pleted): SERVICE CODE: 5 Z� PIE: ZQ <br /> Fee Amount: `'�8 Amount Pald Payment Date <br /> Payment Type Invoice.# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST <br /> REVISED 6-562 <br />