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a R7, k..,rL 1 9 L.L..,� <br /> 11.'24/2014 17:01 2098251004 THEUPSSTORE PAGE 06/06 <br /> NOV 2 4 2014 <br /> SAN JOAQUIN COt'NTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST E-NVIRON MENTAL.HEALTH <br /> t <br /> Type of Business or Property =FACIILITY ICDA# pSERVIC`E REq (� <br /> F)� 0 3 <br /> OWNERIOpERATgR ! CHECK ifSILLI ADDRESS <br /> }` <br /> FACluTrNAME .� 21F <br /> � v9 7-�A <br /> 7&2 <br /> r 37 <br /> SITE 7 <br /> SITE ADDRESS 5IYG3 <br /> I <br /> ZI <br /> 5trctt Nurn bir St Nam <br /> HOME Or MAILING ADDRESS pt Different from Site Address) <br /> Sd'eStNumber Str Name <br /> $TATE ZIP <br /> CITY <br /> EX7, IAPN# LAND USE APPLICATION V <br /> PHONri1 <br /> EXT SOS OtSYAICT Lo CATION CODE. <br /> PHONE#2 <br /> CONTRACTOR! SERVICE REQUESTOR <br /> r 11 <br /> FHComE <br /> STOR r 77 nn CHECK if BILLIN ADDRFSS LL.J <br /> PHONE# Ext. <br /> S NAME tom,r � � r- <br /> („ I- FAx <br /> r MAfLINO ADDRESS I � � ( ) <br /> yl <br /> STATE Zip <br /> BILLING ACKNOINL>nDGEWNT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HCALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as i II entitled on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done In accordance with au SAN JOA LQUIN <br /> CouNTY Ordinance Codes,Standards, STATE a d FEDFR A laws, r <br /> APPLICANT'S SIGNATURE: i/ /G� DATA: / <br /> PROPERTY I BUSINESS OWNER❑ 0PI-RATdR I MANAGER ❑ OTHEI4AUTHORIZED AGENT ❑ Title <br /> IfAPPucANT 13 not fha DILL! PARTY,proof of authorization to sign Is required <br /> Ab-CHOR17ATION TO RE SEINF R N: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of ny and all results,geotechnical data and/or envirunmentai/sltO assessment information <br /> t0 the SAN JOAWIN COUNT/ ENVIRONMENTAL H�ALTH DEPARTMENT as Soon as it is available and at the Same tifne it is provided to the or <br /> my repr9sentative. <br /> TYPE of SERVICE REQUESTED: <br /> COMMENTS: NOV 17 7�1� <br /> SAN JOAQUIN is 1 <br /> HE LFf ENVIF, ..1OuNry <br /> T <br /> DEPAy�'WENT <br /> ACCEPTED BY: �( F E!YtPLOYEE GATE: 11 1,7 14 <br /> EMPLOYEE M. DATE: <br /> ASSIGNED TP: <br /> SERVICE CObE: PIE' 7'30 <br /> Date Service Complated (if already c6r6PIet8p): <br /> g <br /> Fee Amount: Amount Pai�f' '- Payment Date <<'� �' <br /> Received By <br /> Payment Type <br /> Invoice# Check# - <br /> v� <br /> SR FORM(Golden Rod) <br /> EHD 48-02.025 <br /> 07/17/08 <br /> I <br />