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SAN JOAQU#UNTY ENVIRONMENTAL HEALT*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID ID# SERVICE REQUEST# <br /> �yv1 C-�- S"�CvtlOtl T� <br /> OWNER/OPERATOR A I , CHECK if BILLING ADDRESS <br /> avo P7 Cor 1 n Ke JtII <br /> FAULTY NAME M 0�Ct ICA C h e-v r o yl PC(S.f- (�aCyid L[,S� <br /> SITE ADDRESS 10q -79 G4 N Hi d W� r'L�1 �I 1 ��C IC ✓� I S Z"1 Z <br /> Street Number Direction Street Name•J C' ZI Cotla <br /> HOME or MAILING ADDRESS (If Different from Site AddreSS) <br /> Stroet Number t Name <br /> CITY STATE LP <br /> PHONE#1 EST. APN# LAND USE APPLICATION# <br /> (`1251 q98 7217 9 0�(o-0-70 -O� <br /> PHONE#2 EXT. BOB DISTRICT LOCA CODE <br /> (- 231 6)S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEPECK If BILLING ADDRESS <br /> TVR �da <br /> PH 1o/ <br /> �� EST. <br /> BUSINESS NAME <br /> HOME or M1000 <br /> ING ADDRE FAX# <br /> D D 0 Crb�Cavi/ o� STATE�C V�/ ( 1 <br /> ZJP <br /> CITY C(V�,/�(lam. (,A (� l- I r J W <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator thorized age of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associate 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,SATE and FEDERAL laws. 2 <br /> APPLICANT'S SIGNATURE: — DATE: :% 1305 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED <br /> AGENT 'EY✓ft ,S N� <br /> If APPL/CANT is not the B/LL/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 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: <br /> COMMENTS: ( n S Lt I) bleeder`- oo-}- �V f2- L7,J vJA(' .i '`'`��t. <br /> MAR 13 09 <br /> GUNS <br /> PL <br /> ypN JGPG NM SM LIT <br /> EMPLOYEE M DATE: <br /> ACCEPTED BY: ©L.C L/ L::-L ([ir'T �32 r <br /> ASSIGNED TO: lei� L�� EMPLOYEE#: J7 DATE: <br /> Date Service Completed (H already Completed): SERVICE CODE:( �8 PIE: p <br /> Fee Amount: 3 s Q D Amount Paid 31 5 Payment Date 3 3 d <br /> Payment Type L/ Invoice# Check# � ' �_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />