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SAN JOAQUI**ICOUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDA SERVICE REQUEST# <br /> p +C r <br /> OWNER 10 _) �^ (� W,1�t 1 //� <br /> ' an1�L QMiLo / l0 a+i01� CHECK If BILLING ADDRESS <br /> FACILITY NAME ` ,w j l U n _J LJ - -� /(�G,/ _ q <br /> SITE ADDRESS 1 '1 JW . I-10.m M'c r tie i��CO t q C)n Q 5a I o <br /> Street Number Direalan Name de <br /> HOME or MAILING ADDRESS (If Different from Sits Address) .31 d W- 11 Ave- <br /> Street Number Ramat Name <br /> CITY Tt(`Cy� f�/�t Q STATE f� ZIP <br /> PHONE#t EXT. APN# LAND USE A'PPLICATION# <br /> ( 5C)cl) `4 ?6 -q t 4 $ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR� m.-- � fQnt mance . �m�en-� <br /> Ca(O0f(�' ,1 t-tOI7 CHECK If BILLING ADDRESS <br /> f <br /> BUSINESS NAME .� (Y1� �10..t.lr0.n�' -bL -IQIYIivr/+ Corr oralSONE# y, 4-g EXT <br /> - <br /> P <br /> ADDRESS ZIK w• romwoIove (55i ) 43s- gbIa/- z <br /> CITY S! �%e S J1 0 I V G FSI C STATER.A ZIP q.37)1- ly 11 -3 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: G-IIJTk DATE: <br /> t-a3-lq <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORizEDAGENTCY 1�CCDun4be <br /> IfAPPi/CANT is not the Bi6L/NG 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 DRPARTMENT 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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: <br /> Fee Amount: Amount Paid Payment Data <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />