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SAN JOAQuiNe.:OUNTY ENVIRONMENTAL HEALTH>tirfARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ��`,,,/// <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME V' E LLOVJ (%2 t L' [,N-S <br /> SITE ADDRESS 1535 G. PEse,abE- 20 0VE -rT�at;Lf <br /> e Oiumlmr I DirectimStoat Nam city Zip Coop <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number t Na <br /> CITY STATE LP <br /> PHONE#I Exr. APN 0 LAND USE APPLICATION# <br /> I ) <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S 1I GO J C�-I CHECK If BILLING ADDRESS <br /> BUSINESS NAME Co J011G t-1[s I (A E G ILA t )Ca ) 1/4 C_ PHONE# Ev. <br /> HOME Or MAILING ADDRESSFAX# <br /> e-T S ICEJ.pa IA, 1JfL <br /> ` ( I <br /> CITY S'6 N (36 2-IJ a (L4 n I r 10 1 CA STATE LP .L4 L)�L <br /> BILLING ACKNOWLEDGEMENT: 1, 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 'dentified on this form. <br /> I also certify that I have prepared this applicat d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE J t— Ly It PROPERTY/BUSINESS OWNER IJ OPERATOR OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT T Tboc G{ M A a 4&C It <br /> IjAPPLICANT is not the BILLING PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. bum o co N 4'rLrT G a a-o0 rJ to A a la v vA VL S P.ee.G fLS6iL bf LI,OOo &e4 2 <br /> p,L -rArx14 to Od-OcR Io cr—tmooF— Flsu A'+Cl S&/asoR.&) Via'L'14 <br /> HN J6 QSLONE GN�A ht�+y G?U SIL. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />