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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST -�5amc 6,6,3 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> lqr S�OO �� t 7 � <br /> LC/ 4 4 R. 0. ) <br /> OWNER/OPERATOR Sd-FHa�x - <br /> �� IQA CHECK I/BILLING ADORESSO <br /> FACILITY NAME <br /> grrEADDRESS <br /> d i9sor s: cesi�n tZ TfZeey C? <br /> Street Number Direction Street Name [ Zip Cod. <br /> HOME or MAILING ADDRESS (If Different from Site Address( <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I Ex . APN If 2 S S- Z ZO- 0 5( LAND USE APPLICATION# <br /> 12091 dC(2 —/I L7 Zo/ a3 3 7 rl�vn Ovl l� C�1//� �r.tL-c <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORo rL`Z <br /> �K �N< IGH CHECK If BILLING ADDRESSa <br /> BUSINESS NAME I �4". PHONE# Exr. <br /> �� k �� jc.L2UC� v � 2 a oaf <br /> HOME or MAiLINyy ADD S / FAX# <br /> I t 11 Co /r`l Ltd 2C4- (2Ct9) `a 2X/ --80 31 <br /> CITY CI,N T'C LCL STATE C 7 ZIP (?S-3 3`7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or4Cuthonze age- o sa <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated t t t�I tt is project <br /> or activity will be billed to me or my business as identified on this form. Bit .'C4 '/v t�o yy..�� <br /> I also certify that I have prepared this application and that the work to be performed will idon�accordan a with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: a D C ." DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA i/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLMG 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: <br /> COMMENTS: L!ECF1VE[9 <br /> Ar` z152013 <br /> SAN JOAQUIN C0IIINTY <br /> ENVIROMENTAL. <br /> ACCEPTED BY: EMPLOYEE#: rove; ,' DATE: t 1 <br /> ASSIGNED TO: 4,�71�r1 Dlpw EMPLOYEE#: �,-C/.•� O�Ow DATE: <br /> Date Service Completed (if already completed): SERVICE/CODE: 4 1 PIE: �`0_�r <br /> Fee Amount: Amount Paid OCJ� rQ Payment Date �l3 <br /> Payment Type Invoice# Check# 1 I a.Se�-_ eceived By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17t2D03 <br /> r <br />