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SAN JOA(Z.. COUNTY ENVIRONMENTAL HEALTaao:.;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Trc.AAspe,(LrTa, IL9a/-riwC,*-lr-3 FAC>oC) -.� f)x eokt-778� <br /> OWNER/OPERATOR �`,,// <br /> G \_1 Q g-�W 1 DC 1 1 t-a C— CHECK If BILLING ADDRESS <br /> FACILITY NAME Yrs LLOVJ F0-T <br /> SrfEADDRESS I 535 6 PC54,4 De, Q-0 AVE TLA 6,Lf <br /> StraetNumber I et Name CRY Zip Coll. <br /> HOME or MAILING ADDRESS (if Different from She Address) <br /> Sheet Number Street Name <br /> CITY STATE LP <br /> PHONE 91 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 E.. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> S f l Go tJ G / CHECK NBILLING ADDRESS <br /> BusNEss NAME JO f I 6 G f1A 'w V 1 I N L PHONE# <br /> Em. <br /> HOME Or MAILING ADDRESS S ♦'t+rd AA 1� R �'rE A- (s ( FAX# <br /> CITY s,U /J 136 r/,I,) h 4A n I /,O 1 C.•{j STATE LP q.Zy 07: L <br /> BWANG 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 asAidentified on this foinn. <br /> I also certify that I have preparedIINFORM:A <br /> d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandERAL laws. <br /> APPLICANT'S SIGNATURE: DATE. ►- - I <br /> PROPERTY/BUSmESs OWNER❑ AGER ❑ OTHER AUTRORI7.F.D AGENT 4P TLo3"fe P-T M A a 4,&S 2 <br /> I,fAPPL/CANT is noproof of authorization to sign is required TILe <br /> AUTHORIZATION TO RELEION: 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/she 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: ba;" D LON 44L'01G A R.OV rr o' A a ow .A YI. S?.bc.G fvScd- bF L,,OOo t S4 (L <br /> prL T0'v)e IrJ OfLDca i0 QG rv,00E FISH TA>' � Awa SG:Iato rz Vlsty Ll <br /> f4NJ6 Q6L0 ME. Gr-I'TQ bt.GA�G?V vIL. '/- <br /> ACCEPTED BY: EMPLOYEE#: �ar DATE: 1//2-12-c 11 <br /> ASSIGNED TO: ��•-rn n.i EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: `!�S/ P I E:-�2 368" <br /> Fee Amount: ip O(J Amount Paid 6 oo Payment Date \ 2 I <br /> Payment Type ✓i S Invoice# Check# g't I Ly _ Tr 34-S , alReceived By: <br /> EHD 48-02-025 14 9 is 3 - 1 �) <br /> REVISED 11/17/2003 3 b b. 6D JAN 12 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />