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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f 4a I Clrorerw WIC On / Go 33 <br /> O ER/OPERATOIli <br /> /I/J� I_ n n CHECK 11 BILLING ADDRESS <br /> Sadalla-hFACILITY NAME Ba,& // /K ri'!/hC oh Shop <br /> o <br /> SITE ADDRESS .213 S',preGk� lS ®r. 5u, k— /lea n k C,L 47633 <br /> Street Number IDke,67 Street Name C- C" Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C V 1 0 tld L h Street Number <br /> CITYI r.� STATEJ�f4 ZIP / <br /> PZ�I► 606-D-1-3-7Ext• APN# LAND USE APPLICATION# <br /> PHONE#Z E,, BOS DISTRICT LOCATION CODE <br /> ( v ) - 033 <br /> 11 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR i <br /> ct 0 Vva (Vvct1G1 CHECK if BILLING ADDRESS <br /> 7'q <br /> BUSINESS NAME �A 1 ll 1 ��1 � � �� � P # ^` V 1 Exr. <br /> V r <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE CA ZIP <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,S TE and FEDERAL,laws �j 1 <br /> APPLICANT'S SIGNATURE: A,al DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AANAGER ❑ OTHER AUTHORIZED AGENT Ild <br /> If APPLICANT is W 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 a]ld at the same time it is <br /> provided to me or my representative. I� <br /> TYPE OF SERVICE REQUESTED: �l�� avct <br /> COMMENTS: <br /> 4" cc�pg0 <br /> I <br /> E`,o�FCO <br /> ACCEPTED BY: ,r��� Vl EMPLOYEE#: DATE: 3 Z� 't <br /> ASSIGNED TO: 1 /� G EMPLOYEE#: DATE: <br /> Date Service Completed (if already competed): SERVICE CODE: PIE: l <br /> Fee Amount: 1 (J Amount Paid V52- Payment Date 3 Z t <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ,l Y-o .A E LI. <br /> F.4v002,5-2-g. �> <br />