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SAN JOAQUII ' COUNTY ENVIRONMENTAL HEALTH LEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I c-K b LA —Aron S L C C— <br /> FACILITY NAME / <br /> 141 c-K 6L ar MS 13-1 lI <br /> SITE ADDRESS Pac t [G Q Ix— C?�_ r~j 0-7 <br /> l J 6 Street Number Direction Street Name U�� Cit ZI Code <br /> rH�OMEE or MAILING ADDRESS (If Different from Site Address) <br /> r`l d' D� 1 ti(1 116, It d. '911 h'Aa cll j cl s 1 Street Name <br /> CITY t STATEn ZIP ,/ d/ <br /> V t( <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (q1 ) -1 33(o f b-22 ) 9 <br /> PHONE#2 ExT• BOS DISTR1C LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ����./{� <br /> CHECK if BILLING ADDRES>:r1Cd <br /> BUSINESS NAMEPHONE# EXT. <br /> --7 <br /> HOME or MAILING ADDRESS J4� FAX# <br /> l 0, L ( 1 <br /> CITY —(A-ed <br /> ( -e 3 STATE (+ ZIP J <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 all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:41 if <br /> PROPERTY/BUSINESS OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT d og I <br /> If APPLicANT 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 /> 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 TYPE OF SERVICE REQUESTED: {?( �L L-oe(eq-k <br /> L Cr /"c/ K", 0.1( U. I ( 5t > ! Q 1 A <br /> COMMENTS: n n f(�X �Q T � (�"` �J(�rL"X`l 1(I�- _ /( ��` l� — /��3I� (7 � RFC'�EN <br /> N v FrvE <br /> '% 31 <br /> ?0� <br /> H RC Co <br /> 4 M'q <br /> ACCEPTED BY: EMPLOYEE M DATE:o. _ f� <br /> ASSIGNED TO: � Cihd Z- EMPLOYEE M DATE: -7. ) _ / J—7 <br /> Date Service Completed (if already completed): SERVICE CODE: L� P/E <br /> Fee Amount: ca-- � Amount Paid 57 Payment Date 3` L1r�v <br /> Payment Type c. Invoice# Check# Receive By: <br /> EHD 48-02-025SIR <br /> uh� �f �+S�G �v SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �V�Gt <br />