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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VV <br /> OWNER/OPERATOR <br /> �! A CHECK If BILLING ADDRESS� <br /> FACILITY NAME11,49 7 Ln <br /> n� e C. <br /> 11 <br /> SITE ADDRESS 1DOPB / / `1lAf� /ZDG(�E �9 �/?OnIY�44 'S�OCI�i� 9�af.Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT- APN# LAND USE APPLICATION# <br /> (C�o�) �3/- -5-4 o -o p -47 <br /> PHONE#2 EXT• BOS DISTRICTLOCATION CODE <br /> o ► 333 -,M6 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Dln CHECK if BILLING ADDRESS <br /> BUSINESS NAME � �( L PHONE# EXT. <br /> rV, 00 4�1_ (a0 ) o - <br /> HOME Or MAILING DRESS FAX# <br /> QZ14:� ( ) <br /> CITY STATE 09 ZIP !�_30 <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,Standards,S E and FED laws. <br /> APPLICANT'S SIGNATURE: DATE:/ AO//O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/T8NAGEROTHER AUTHORIZED AGENT Lld <br /> If APPLIC.AN7'is not the BILLING PARTY,proof of a thorization 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, geotech-nical data and/or environmental/Sit — <br /> information to tile Q� M e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s Y <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUEST D: AXP RE V/6 W - S NY OCT 10 7122 <br /> COMMENTS: <br /> J <br /> OAQUIN COUNTY <br /> ! IRONMEN AL <br /> DEPART MENT <br /> .k <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> hinli <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: �2— <br /> '7 <br /> Fee Amount: Amount Paid 493(_0.-- Payment Date I n1(0 !� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />