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SAN JOAQUI'*UNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> as n, 3 ? rO <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �� <br /> • FACILITY NAME 5lLaj <br /> SITE ADDRESS 3725 Tr a C y 6) /d. L ' Q C V <br /> Street Number Direction Street Name city zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) m /o 1V 8,12—,1250/-) t,4�V_e <br /> Street Number Street Name <br /> CITY d— STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# Q �O <br /> ( ) 39 �y a�� 2( Z <br /> PHONE#Z EXT. BOS DISTRICT '5— LOCATI(YJ CODE <br /> 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 1 <br /> CITY STATE ZIP <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 rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERR OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPS/CANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as I Is available and at the same time it is <br /> provided to me or my representative. Lk, T cd Lt L��4 IZ v <br /> TYPE OF SERVICE REQUESTED: ` <br /> COMMENTS: C"S4zi'2,1 9a S 5+o--ti-z4 RECEIVED <br /> JUN 2 1 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ©�i v I EMPLOYEE#: J L DATE: &12-fll O <br /> ASSIGNED TO: 1-L Jji� 4Av EMPLOYEE#: L�Z ( DATE: /_ � <-0 <br /> Date Service Completed (if already completed): SERVICE CODE: O/'- �(P 1'E: 3 <br /> Fee Amount: �� Amount Paid ` s — Payment Date 2( I O <br /> Payment Type ✓ Invoice# Check# u 3 S 1 Received By: N-1-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />