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SANJOA OUNTY ENVIRONMENTAL HEAdWEPARTMENT <br /> SERVICE REQUEST <br /> Type of husiAss or Property FACILITY ID# SERVICE REQUEST# <br /> j2C)6 - C, o-U <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS EI <br /> QP wssT RNs, LLL <br /> FACILITY NAME �Q C o 4� N" I (�M <br /> SITE ADDRESS � �0 N for S\ 0 cc T.) <br /> rtreet Number Direction Slreel Name Cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# D 1 LAND USE APPLICATION# <br /> ( ) 1731 ' C <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR nn CHECK If BILLING ADDRESS <br /> N taw - F + ' <br /> BUSINESS NAME ^ PHONE# p EXT' <br /> N 11 <br /> HOME Or MAILING ADDRESS FAX# <br /> R OS CAZA ) 691 -144 <br /> CITY A F J STATE CIA ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 the 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 an S <br /> �( APPLICANT'S SIGNATURE: DATE: /�, A '2 <br /> ✓ ' PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED ACF.NT9 Ab%,NT Caxr <br /> ifAPPL1CANT is not the BILLING 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 /> infomtatiotl t0 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: L,,-S7- 4-1-E-7-4O F I T <br /> COMMENTS: RECEIVED <br /> Nov 13 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> IjEALTH DEPARTMENT <br /> APPROVED BY: 6L( L/41-- EMPLOYEE M 632-/ DATE: /I f31O3 <br /> ASSIGNED TO: dJ-AC-V$ NI EMPLOYEE 3-7-3 ry DATE: It /3/Q3 <br /> Date SBNICe Completed (if already completed): SERVICE CODE: / 9,S P 1 E: -2-3-09 <br /> Fee Amount: -7�l ,p L) Amount Paida Payment Date �I 3 <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-01.025 SERVICE REQUEST FOR <br /> REVISED 6-5-02 <br />