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SAN JOAQUIN VOUNTY ENVIRONMENTAL HEALTH it EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE RE EST# <br /> OU1.11 tZ IAb=E 39- 016G Pooh 63f <br /> OWNER/OPERATOR .fii(al/i/,4s�� <br /> CnLSIt it BIWESa <br /> NG ADDR <br /> C � <br /> FALTury NAME <br /> ( <br /> SITnEE ADDRRr��ESS a S Z-o <br /> I _l 9 Street Number Direction N, �' Stree[2 0 '�" ' a Cha <br /> HOME Or MAILING ADDRESS (U Different from Site Address) <br /> Slnee[Number Street <br /> CITU STATE LP <br /> PHONE#1 E.' APN# LAND USE APPLICATION I# <br /> ( ) <br /> PHONE#2 EMD6rRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK N BR.LiNG ADDREss <br /> BusNEss NAME' PHOME# <br /> Q2 <br /> HOME or MAILING ADDRESS FAX# <br /> 44 64 1 - 2- (9LS ) 1 G 51 <br /> CrtY I ,J STATE LP C' <br /> 311 <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 C,'adrs,Standards,STA and � •DERRAL laws. <br /> APPLICANT'S SIGNATURE: - 1 — DATE: <br /> (0 kylv 9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN CHR ❑ OTHER AUTHORIZED AGENT Id 0"1 SlaT FD <br /> JfAPPL[CANT is not the BJLLING PARTr.p authorization to sign is required Ti/le <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 i3 <br /> provided to me or my representative. <br /> TYPE OF SerAm REQUESTED: <br /> t aIe®Its: 200' N�ON 2 3 ?000 <br /> ,104CNuep OUN Nr <br /> AccEPTEDBY. SrJ t N EMPLovEE#: DATE: a <br /> ASSIGNED TO: EMPLOYEE#: 6 DATE: <br /> Date Service Completed (it already completed): SEIMCECO E: 5 Y PIE: Y <br /> Fee Amount Amount Paid a l _ Payment Date (p (2 3 b 9 <br /> Payment Type l/ Invoice# Check# S D '`t� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />