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SAN JOAQU P, <br /> OUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S, .-T la m RQD MDwT %N00055-c 52.007 0 6(; <br /> OWNER/OPERATOR <br /> r n N CHECK if BILLING ADDRES <br /> FACILITY NAME Q <br /> s <br /> SITE ADDRESS I Imo'"- , v '(,T(j 9— LUfa N g52,q O <br /> 286 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam® <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 269- 09S% _ 4 .322— <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> 56,1-3 ,, <br /> 04- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n <br /> /!�. Av t q� CHECK If BILLINGADDR <br /> BUSINESS NAME ��,WWW W PHONE#qwtv, PU tc, A Paz)Z) M Prcf <br /> ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP C)SIS -- <br /> BILLING ACKNOWLEDGEMENT: 1, 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 law r <br /> APPLICANT'S SIGNATURE: DATE: o <br /> PROPERTY/BUSINESS OWNERf'�yyOPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 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: ri <br /> COMMENTS: <br /> aj D-*� RECEIVE <br /> SEP 2 2 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: m ., /t 1�Cu EMPLOYEE#: A <br /> ASSIGNED TO: 9 9- �/1 ,nl EMPLOYEE#: DATE: <br /> Date Service Completed (if already pleted): SERVICE CODE: ®� , P 1 E: 6 D Z <br /> Fee Amount: I�® Amount Paid ✓ Payment Date ,R <br /> Payment Type ,� Invoice# Check#1 ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />