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JAN JOAQUIN k OUN'I'Y L'NVIRUNMEN'IAL nEAL'I'H IIEPAR'I'MENI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SIeDo � 3al � <br /> OWNER/ OPERATOR <br /> �EN )L.,(LAWLErl CHECK if BILLING ADDRESS <br /> FACILRYNAME )LENWtE(L �JtrIE�(pr(z-�S <br /> SITE ADDRESS28'31 �l IJ t-J gS-Cos-y <br /> Street Number Olrectlon Street Name cityZIP Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z9 IR k W . (2T:,. <br /> Street Number Street Name <br /> CITY t-oD) STATE C--�s ZIP 85247- <br /> PHONE#1 <br /> 2PHONE#1 En. APN# LAND USE APPLICATION# <br /> (ZcR ) 491 -41o39 col - 1-�>O -oy- pfr - 10002 3 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR J <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMELI�� per- C�Eo ENVIRON H'tEN�. L PHONE# Exr. <br /> 2041 1 3109-O3-qS <br /> HOME Or MAILING ADDRESS 4o,} vo t7A10- 9--- FAX# <br /> moa) 3'> -o3`� } <br /> CITY L—DD L STATE CA ZIP CJS7-+D <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,STATE and FEDERAL I WS. <br /> APPLICANT'S SIGNATURE: DATE: _// <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLicA.AT is not the BiLuNG PA proof of authorization to sign is required Titre <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 environmentaVsite assessment <br /> information t0 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: ftqIEW $Ott- SUfr1'5I —ITyQ/'tVITR+°�'TE L0M>fAJ& S`T-VDy .SME �t + <br /> COMMENTS: LOM //! 9Mle( �IZ' !/ V/zS/i'_ r 1Q hO�\ <br /> �'P�-1 fZU/ � (yid or, UIN OOUN� <br /> ,OAQ MEpYN- <br /> ClLZin/�J) - <br /> ACCEPTED BV: Et#: DATE:ASSIGNEDTO: I #: C� DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: z PIE: <br /> Fee Amount: Amount Paid 25�� Payment Date �L <br /> Payment TypeInvoice# Check# `-110 4 - $ 1 D D-0 Recelved By: <br /> EHD 48-02-025 CA Stt- g 1 S SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />