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SAN .JOAQ1000UNTY ENVIRONMENTAL HEALTHIPZ:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LIQVUIZ STBRC-� 6AS STkTIow 0 3�1�1� S 2cv73S-�S <br /> OWNER/OPERATOR GOVINDIE—D �N/ u /I � Ip <br /> 7� � v I I l �'( W I 1 CHECK If BILLING ADDRESS <br /> FAciury NAME PLft2A uRIJoR #- 1 <br /> SITE ADDRESS p 0 SC EK0<6 LN 'LOT)I I9 52-H O <br /> AN umber Direction Street Name city21 Code <br /> P)ME Or MAILING ADDRESS (If Different from Site Address) <br /> 54¢et Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> (20q) 53LA 18Lio <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 368 0 12-7 11 <br /> �y <br /> CONTRACT <br /> �tOR/ SERVICE REQUESTOR <br /> REQUESTOR rOV1 ��zJ C +l'�� �. <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 LAZA L1aw, # 1 PHONE# 5 3 t.l I 0 O En <br /> P <br /> HOME Or MAILING ADDRESS 3O0 -5 / + A L 'r�6 y' 66 F e4q) 3 f&-6 17-7 <br /> CITY 1 O fin (, l�'l Gl`^' STATE C - JE7 zip Cr Jsp <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 FEDERAL laws. ; <br /> APPLICANT'S SIGNATURE: �ys��ei �f {Jcr� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ W"!y'IC. <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION; When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the sarpe ypit*itig,arpyjded to me or <br /> my representative. 1r'HY�IY�IC� r �� <br /> TYPE OF SERVICE REQUESTED: UG ` C�j✓�jl,t.�-�lYi (61�� <br /> HIECEIVED <br /> COMMENTS: NUV U 6 i�U l <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: II <br /> ASSIGNED TO: Avi <br /> <, Q,{©!/l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s'C,_!;& l PIE: <br /> Fee Amount: Amount Paid J 3 C9C9 () Payment Date <br /> Payment Type C�1S� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />