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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> No <br /> S�DO �35�P <br /> OWNER/OPERATOR <br /> Lod, ZO S ^o 1 / I< �J^ � CHECK If BILLING ADORESSW <br /> FACILITY NAME 'O 1 //R's ( lJ <br /> SITE ADDRESS .. -75- <br /> Street <br /> SStreet Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Eu. APN# LAND USE APPLICATION 1# <br /> Pv9133 / —x1,97 <br /> PHONE#2 EXT. BIOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADORESs <br /> '—RD6,4,79- <br /> BUSINESS NAME —gay <br /> I ' PHONE# ExT' <br /> p / fsF3 33'F 2Io17 <br /> NQULOKMAIu G ADDRESS FAX# <br /> 5 oP L ( ) <br /> CITY Lod. STATE C/1_ ZIP 9s a 4.0 <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 <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,Standard and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: �a y -aoay <br /> PROPERTY/BUSINESS OWNER❑ OP' \TOR/D'IANAGERA OTHER AUTHORIZED AGENT 11 <br /> /f APPLICANT is nor the BILL/NG PARTY proof of aatliorization 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: � A r <br /> COMMENTS: <NVIRD(JMLNTI�LJ �ea1` --TnsFeADA) �'F YSl-4G�eyt. EQ <br /> .fAR 0 4 <br /> E�lNF t I O/V cc /V y <br /> ACCEPTED BY: EMPLOYEE#: L'\3 DATE: '� NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: 3141 <br /> V <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: O <br /> Fee Amount: Amount Pai Q D Payment Date <br /> Payment Type A invoice# Check# / Recel ed By: <br /> EHD I SR <br /> _F <br /> ORM(Golden Rod) <br /> REVISED 11/17/2003 ?ayam Cl§AfvryD <br />