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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT A l ?) -Q4 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SEAVICE REQUEST# <br /> -7 Q UI&V0730 <br /> OWNER/OPERATOR 4'` �, r ; LLC <br /> C CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 1 c toyrns <br /> I -2su I <br /> SITE ADDRESS —FT <br /> „ ` 1►/(�, (�� \� <br /> Street Number Direction &M111v � <br /> HOME or MAILING ADDR S (If Diffe ent from/S'ite Address) (� �I� ��� f`�'/�� '� <br /> 1'I 1 1 n ' t �'Stree�hlber t? Y 'Street Name <br /> CITY -3-a <br /> ; I — STATE ZIP C <br /> PHONE#1 E.T• APN# LAND USE APPLICATION# 3 <br /> (51S) Lii.Pa.cla��� 1q,3(6 <br /> PHONE#2 \ ,^ ExT• BOS DISTRICT LOCATION CODE <br /> ( ) N <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORr <br /> J�� ( \I /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME ` ' J 1 m v& �u `n r� PONE# 4; 9 • � Ems' <br /> HOME or MAILING ADDRESS 1 ,+ J- FAX# <br /> 1 Pr ( ) <br /> CITY -Td 1 P-�- <br /> STATE zip <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 /> APPLICANT'S SIGNATURE: DATE: , C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTv J �T <br /> If APPL/CANT is not the BILLING PART_,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: Pt f m l� noy'aly. +1xn00 y mu V L l /CA Gt1 <br /> COMMENTS: C( f o l d Jl i L C4— UO&A t li Y) 11 I I IV f. <br /> UN 13 20 <br /> SAN NVIAQUIN Cp <br /> ux 7-Y <br /> ACCEPTED BY: Ca ��/� 5 �� EMPLOYEE#: DATE: �� l PEF,�' 7A[ <br /> EA T <br /> ASSIGNED TO: l �'l.7 EMPLOYEE#: DATE: (�, (2 <br /> Date Service Completed (if already completed): SERVICE CODE: G P 1 E: �C� <br /> Fee Amount: ( _ Amount Paid' /� 6Payment Date 311 <br /> Payment Type Invoice# Z�Z I Check# /837 q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />