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p I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type oyyf''Business <br /> `or/Property FACILITY ID <br /> 'MW V V 1 CI # SERVICE REQUEST# <br /> W IFI-E SIA M� I-- -,CD 7. <br /> OWNER 1 OPERATOR h1` / / (� r/ i <br /> ,` ]`�l� � UOS 1 [ IFF EE - CNECKIfBILLINGADDRE55C� <br /> FACIIITYNAME I ITTC `(jTS. COFIFE6 <br /> SITE ADDRESS J �1i+'5- �--�J- ��l l � UIU 1..1 l l �O!U lq5�ZqrNumber Direction . Street ame <br /> HOME or MAIUNG;ADDRESS (if Different from Site Address) <br /> Street Numberl�Stree!Name <br /> CITY rC� :���! STATE Z1P - GJ `.r'" <br /> PHONE#1 ExT" APN# LAND USE APPLICATION <br /> PHONE#Z E T BO5 DISTRICT LOCATION CODE <br /> ' CONTRACTOR'/SERVICE REQUESTOR <br /> REQUESTOR ,�I� <br /> �� 1 N U s CVFE EF <br /> CHECK If BILLING <br /> BUSINESS NAME D i( (k"7 [-,{ E 11 Q N S.` u CTl �," ��/� SONE# <br /> lJ JV 1 t CLL V �J �• �f f � � �Q . <br /> HOME or MAILING ADDRESS (j Q O, ST. r a FAX# <br /> IF CITYSTATE ZIP <br /> �S� .�IICYP'ly\E �" � <br /> TI IV tls <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 <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 aIl:8ANJOAQUnv <br /> COUNTY Ordinance Codes,Standards,ST d FED E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BVSINESS OwNEIO OPERATOR/MANAGER 13 01r ER AUTHORIzED AG£NT© _ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Tt rl e <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 i5 available and at the Same time it is <br /> provided to me or my representative. f <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Ir <br /> AUG 2 5 .201 <br /> `— SAID JOAn!1ik i <br /> FL <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> AsSIGNEDTO: �L,�,.L EMPLOYEE#:' DATE: —25 �6:7 <br /> Date Service Completed (if already completed): SERVICE CODE: s�Z4 P i E: <br /> Fee Amount: Amount Paid e J Payment Date oZ <br /> Payment Type 't S Invoice# Cime , )$7 Received By' <br /> y <br /> i <br /> EHD 48-02-025 T_,j/ SR FORM(Golden Rod) <br /> REVISED 11117/2003 i e 1 z� r2-4-16 tta <br /> Y I <br />