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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L m e21vD AA IV CA! <br /> OWNER I OPERATOR <br /> E T� m /L r CHECK If BILLING ADDRESS <br /> FACILITY NAME �/ <br /> /-64i:2 TL <br /> SITE ADDRESS 170 -7,1 7fZ�E ES� LUN 9�3Z� <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> • Street Number Street Name <br /> CITY STATE ZIP <br /> �nl�s ez mE.v� CA 9 <br /> PHONE#1 Ear' APN# LAND USE APPLICATION# <br /> (N) 3 —55 f- — —3 Z <br /> PHONE#2 Ezr. HOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> IQ 4E5NE 5GCL7- ag-423 <br /> HOME or MAILING ADDRESS FAX# <br /> . o . box 37,74 1 <br /> CITY /—O C— STATE CA <br /> 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 app 'cation and that a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S' E and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT <br /> IfAPPL7CANTisnolthe BlLLtNGPARTY 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 /> inf natation 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 /I <br /> II - <br /> PAYMENT <br /> COMMENTS: L / Sf <br /> `lB (illj �T ti y rtl-J,/ NOV 2 4 2008 <br /> /IAOCSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ID irN. n HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3� DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: / <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />