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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 74 75 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5� o <br /> OWNER/OPERATOR <br /> 1 `r LLC <br /> C CHECK If BILLING ADDRESS O <br /> toyms <br /> FACILITY NAME c \ ` �/� ] 1'2—?'LQ LP <br /> SITE ADDRESS Q006 5T (IN CA <br /> Street Number Direction I Co e <br /> 6 <br /> HOME or MAILING ADDR S (If DiffeEent from Site Address) Ip t��Q <br /> LLL a t1h Rc re4 Nafiber � I 110 • Street Nl <br /> CITY T I t STATE ZIP r� <br /> PHONE#1 lJ T� ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 \ ,^ Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR130� `�� — ` I (( \ <br /> 1� v f�� 1- CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME m� 1 I� r.n 1PONE# � � Ems• <br /> HOME or MAILING ADDRESS ,� 1 '+ FAx# ) ` <br /> mejo <br /> CITY $TATE ZIP <br /> J- 1 t r— <br /> f <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 /> I also certify that I have prepared this application a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a DE4AL laws. <br /> � C� <br /> APPLICANT'S SIGNATURE: DATE: 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTV V C ���T <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 /> irformat;or: 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: f 11 1 k tft�al� CAr 'C-- <br /> COMMENTS: /, !a" ' <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ILL <br /> b <br />