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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ft SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `�yq <br /> OWNER/ OPERATOR <br /> Va- ey ()cranks, T7nc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Lc7L17.rop CC>Ylipost site <br /> SITE ADDRESS <br /> J Street Number U Direction f re--we r Street Name Lathrop city 95330 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Lower SacraIaento Roo <br /> 12900 Street Number Street Name <br /> CITY STATE ZIP <br /> 'od <br /> A CA 95242 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (120S'' ) 334®3659 19'_--•260?-22 PA0500726 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> T:ie c^, CHECK If BILLING ADDRESS <br /> S <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 or <br /> 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 FEDE 1 s. <br /> APPLICANT'S SIGNATURE: DATE:/® <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 1_I OTHER AUTHORIZED AGENT❑ Pre n i de Sl yr <br /> IfAPPLiCANT 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: C EN <br /> COMMENTS: y G�w rs Li/Z5/�'7 C' 1 3 2001 <br /> QUw cooNN <br /> SA ENN RONME�MEN <br /> I;1EAt-TN DEPA <br /> ACCEPTED BY: �r p Q _ ( � EMPLOYEEM ^s!� DATE: 2 -4 67 <br /> ASSIGNED TO: , EMPLOYEE#: DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: S'2`Z. P 1 E: Q <br /> Fee Amount: Cs Amount Paid -7�j ! U U Payment Date 3 Uri <br /> Payment Type/ M` �V Invoice# l Check# Received By: <br /> EHD 48-02-025 11tI � 2 J SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />