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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> /REQUEST# <br /> W//JFR RE5/D�NCF Db CJe2iS� �y <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSLYJ <br /> L E lE <br /> FACILITY NAME <br /> W/ //7ic Z- R/Dl E W1,1V <br /> SITE ADDRESS 8338 W I/N.VE r2D- %2AC�/ 9530¢ <br /> Street Number Direction Street Name Cil Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 5 /✓I£ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I �T APN If LAND USE APPLICATION# <br /> (-70f ) 3 -0005 as3 -at o -3P P - 050044 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR t(1"te"Tr, <br /> REQU � Cl•EESNE <br /> ESTOR CHECK If BILLING ADDRESS LI <br /> BUSINESS NAME PHONE# E'T' <br /> zap <br /> HOME Or MAILING ADDRESS FAX# <br /> �. o • SoX 37R� ( ) <br /> CITY Tu�OG� STATE CA ZIP S / <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 <br /> or 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, TE and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: 1- 7-13 1— 7-13 <br /> M <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT IW <br /> If APPLICANT is not the B/LL/NG PAR 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:iV/s •rP LOA,oM. fV14 fUrrA Sitlr 5 r O iBs ADDF.VDie n <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> Qt�,C�d e^) JAN 07 2013 <br /> rSAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: D TE. ENT <br /> ASSIGNED TO: AS I <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (If ready completed): SERVICE CooE: P/E: p 2— <br /> Fee <br /> Fee Amount: r� Amount Paid 7 Payment Date ,' 1 <br /> Payment Type % invoice# Check# C32 2Received By: .( <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />