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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> �� `� 'S6 aa� <br /> cru � - <br /> -OWNER/OPERATOR _ CHECK if BILLING ADDRESS <br /> A1ne5- AC�eo - O e / UV <br /> FACILITY NAME p A dZ <br /> SITE ADDRESS 9g5G i/I/E�j1— r7'TA7 Tl�u� �2 LOD/ 95 2-4 <br /> Street Name CI Zi Code <br /> Street Number Direction D2/(lam <br /> 70�HOME or MAILING ADDRESS (If Different from Site Address) S/m oma/ <br /> Sheet Number Slr N me <br /> CITY STATE CA LP <br /> Ari <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> V/6 ) 32¢- o s- - o P -o - s u o0o 337 <br /> PHONE#2 EMBOS DISTRICT LOCAN ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /jam/ CHECK if BILLING ADDRESS <br /> Err. <br /> BUSINESS NAME PHONE# <br /> I E�51V E Ca N LT nl <br /> HOME or MAILING ADDRESS FAX# <br /> p Q - gay ( 1 �68-zSYB <br /> CITY �/ STATE ZIP 3 <br /> 1 LO Lg. <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDH ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MI AGER ❑ OT R AUTHORIZED AGENTi <br /> ff <br /> If APPLICANT is not the BILLING 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 environntental/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: Q L TA / MENT <br /> COMMENTS: DEC 3 0 2008 <br /> �1� /p�i� /TPvif� SAN J <br /> `L' �a3/�'� ENVIiROU1 EN-r,Ty <br /> �k HEALTH DEPARTM NT <br /> ACCEPTED BY: Q LC VAC Z <br /> / DATE: / 0/0 6 <br /> ASSIGNED TO: DATE: /Z .?� D8Date Service Completed (if already completed): E: SZ2 PIE: plodFee Amount: ,5f �.t ,OD Amount Paid ayment Date 3Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />