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9:55 07 L t <br /> Today Edit <br /> 9=51 AM <br /> www.sj,cehd.com <br /> SAN JOAQum COUNTS ENVIRONMENTAL HEALTH DEPARTNIE,NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID/ SE E R UF$7 <br /> U&U/!Z <br /> ()INNER/OPERATOR o Z—/VC L v,<- -41'e t._./ <br /> / C}I@C'Kn 81U_INO ADOAEB°® <br /> FACu"NAME E S L,r c (, .� ,J / <br /> siTj:ADDREsa ,N S T— Tfj�A y C/-'�3'1(v <br /> HO/ME Of MAIuNG ADDRESS IN Different from She1Addri ul'r1 <br /> CITY STATE I ZIP <br /> PHONE101 APN N LAND Use APPLICATION q <br /> PHoNr A2 OIs. BOS DISTRICT LOCATION Goof <br /> 1 ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REGIUESTOR `r A/'CI L rlJ&k /CAI KA ND <br /> Busuntoo,NAME <br /> ,.........,.�............... F <br /> Halts Or kiALala ADDRESS <br /> Cm STATE 21P C `Z <br /> BILLJ NG ACKN 1W.H :A9.NT: 1,the'undersigned property lu business owner,operator or authorized agent of sante, <br /> acknowledge that all site andim project specific ENVIRONMENTAI.HEALTH DEPART%ivsrr hourly charges asulciated with this plvject <br /> Of activity will be billei to Inc or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JDAO(!iN A <br /> (OUNTy Ordinance(oder,5 "'J,rd(STA/TE�od FEDERAL laws. <br /> APPLICANT'S SIGNATME: �rrwwr� l ( DATE: <br /> PROPERTY t BUNINESNOWNERLJ OPERATOW.MANAG91113 OTHics Av'rooaIZED Aczxr 13� <br /> II APPUCAN7 is not the dU&JJPAArr.prop f of aathorization to sign A required rtt7� ry <br /> AUTHORI7ATION TO R@.LEASE INFORMATION:When applicable,1,the owner or operator of the property located at tIT�A--� <br /> above site address,hereby authorize the release of any and all results,geotechnical data indoor envirOnmetltalisite assessmenvi-i i/ �Q�'N ?o�jJ <br /> informali0IT to the SAN JOAQUIN COUNTY ENYIRONMEN'rAL HEALTH DLPART'MLNT as soon as it is available and at the surae time[JrLytt "W J <br /> provided to me or my representative, c'RD CO <br /> TYPE OF SERVICE REOUEETED: �w ,,`N? , <br /> COMMENTS: p^t . ,Aar <br /> T <br /> ACCEPTED BY: EMPLOYEE tY: )A-.- 3113 , <br /> ASSIGNED TO: (a on v ELWLOYEEN: DATE: <br /> Data Service Completed (if already completed): SWAMCOOE: f PIE' <br /> Fee Amoun2(,4i Amount Pa payment Date <br /> Payment Type Invoice If J Check M hoceIVA By: <br /> EHD 4"2 025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> _.......__. ......_......... ......... _ ......-........._.. .__.. .. ... ...._........_ ........... <br /> 41 <br /> 2�� <br />