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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� 0D'31`lS�- <br /> OWNER/ PERATOR ` <br /> e ` A \ V CHECKUDILLINa ADDRESS <br /> Tre <br /> FACILITY NAME "`ITT <br /> $READDRESS S -1110 �YJYL �G L Qt52�15 <br /> 3gcbaSMIt NnmNr Dime".. St". Nam. C ZIP Coda <br /> HOME or MAKING ADDRESS 010 nt f m Site Ad ) -F LI <br /> ( t Srna[NumMr m <br /> CRY , 1 rO C44 STATE ZIP <br /> PNQNNE##1 p xT. APN0 LAND USE APPt]CAnoN0 <br /> (2t IP ` Q b <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK I1 BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ea. <br /> HOME or MAIUNO ADDRESS Fax# <br /> I ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTrt DEPARTMENT hourly charges associated with this project <br /> or activity will be billed tome 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 /> Com"Ordinance Codes,Standa , TE an gs�AL ws. <br /> APPLICANT'S SIGNATURE`( .DATE:j F /7 JI) 7 A <br /> PROPERTYi BUST\TSs011:YER❑ OPERATOR/LAGER ❑ 0TIIERAVr11OIUzEDACE.\T❑ <br /> ZrAPPLICANTfsnot1hcfiLLINGPARTTtproofofaulhorizaAontosignisrequired Title <br /> AUTTIOR17.ATION 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 andfor cnvironmentallsitc assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HP.ALTit DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. 'Q <br /> TYPE OF SERVICE REQUESTED: ��, C' T <br /> COMMENTS of <br /> s <br /> ?-/y Nf4oulv <br /> MFNT <br /> ACCEPTED BY: EMPLOYEEM DATE: fl2-r- 1q! <br /> ASSIGNED TO: O EMPLOYEE#: DATE: (l 0 <br /> S <br /> Data Service Completed (if already completed): SERVICECODE (7w PiE:[4(2 <br /> Fee Amount: Ci2� Amount Pald W.'-o Payment Data // <br /> Payment Typo invoice# Check# ��(, /7 Reco ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />