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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q <br /> OWNE OPERATOR ( [C Z✓1 CL r t Sa ro vp L Iva �t —11 ) <br /> O j'TUT Orli 4� CHECK If BILLING ADDRESS <br /> CCygjtl _ �.- ie �S K e°vJ2 �VOCCLA' 1 '1 <br /> FACILITY NAME —1 b S�� d hu Sy �cf IJ;; Q I io 4a 'LI e EQ�IY.t°'P/� �] <br /> SITE ADDRESS Z IbZ410 S 1� rc,0 aV T (� C <br /> Z46 Soo Street Number Direction Street Name CI 1 Z Lotle <br /> HOME or MAILING AD�D�RE/$S (If Different from Site Address) 1-fie It TZ� �,C1 <br /> 3 7 Z Y y . 2 "TI. a,n 1L � Street Number �u R YI Q b'7 Street Name <br /> CITY �` SZac CN TA 4530 <br /> PHONE#t /<4 V-k Ctr /Mi � I Exr. APN#5 Z FJc? [ <br /> — ,90 11, LAND USE APPLICATION# <br /> (ZAe1 ) (� I2 - t12.7 7--L, -30 � 3� <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU'ST CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NIAME-- PHONE# Ezr. <br /> / ZI �� Sct �J� tti l _Jrto W 26gZyd- eodL/ <br /> HOME or MAILING ADDRESS FA%# <br /> 11 -740 kbfZ C (w1) 82i< — -Z / <br /> CITY I4 N I e C-q <br /> C R STATE CH ZIP <br /> l/ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE CD C-'Q DATE: <br /> ( / ZO 13 <br /> PROPERTY/BUSINESS OWNER❑ OPERA O MANAGER 11 OTHER AUTHORIZED AGENT/� Lr C[Yl$[G L1A1iC� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required T/ �S u R 0 <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 OF SERVICE REQUESTED: <br /> COMMENTS: 93ECEIVED <br /> 1---d 0 7 2013 <br /> SAN JOAQUIN COUN Ty <br /> ENVIROMENTAL <br /> 3 T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: O EMPLOYEE#: DATE: 'V1 rt <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: d <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 />