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4 <br /> SAN JOAQUIN )Ut4TY ENVIRONMENTAL HEALTH 1 .'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CtA-s ST- Coil WOO 55 09 <br /> OWNER/OPERATOR /// <br /> u-C ('S J�(.�(�0 ko- CHECK if BILLING ADDRESS <br /> FACILITY NAME V <br /> SITE ADDRESSj� 3�INumberrDi\yjrection Street Name Cit l 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# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILUNG.ADDRESS <br /> BUSINESSPIAME '5+*: 'WILA sf- vv_& LLC PHOb& O3 9 EXT. <br /> HOME or MAILING ADDR, S+ k t FAX# �U <br /> � � &ULua f1u� ('fck) 1c3 — <br /> CITY C tLLX (^sem STATE 04 <br /> ZIP 9s1 (� <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 as identified on this form. <br /> 1 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(,odes,Standards,STATE- and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DAI"E: <br /> PROPERTY/1311SINESSOWNFR❑ OI'FRA'rOR/MANAGER ❑ 0THERAUTII0RI'ZEDACEN'I'i4 Cowylt xux 04dz ► <br /> ifAPPLIC'ANT is not the BILLING PARTY,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: v S r <br /> COMMENTS: �'p�L� {� j[I�. ! �p t l CSC U�'1 ( LOO <br /> SAN JOAC)"N COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: G- EMPLOYEE#: DATE: <br /> ASSIGNED TO: yj EMPLOYEE#: � DATE: <br /> Date Service Completed (if already Compl ted): SERVICE CODE: / P/E: <br /> Fee Amount: �S `�� Amount Paid R1kt ( S / <br /> Payment Date S cl D <br /> Payment Type ✓ Invoice# Check# Received By: ►V `f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />