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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CamM,F)w1,4 Z :15rlyl30P � <br /> OWNER IA OPERATOR - /^ '/ <br /> e4A L T 2 CHECK If BILLING ADDRESS <br /> FACILITY NAME 0 SNDVS/TR/AL 2K <br /> SITE ADDRESS( C�I. 2(5/h,4 <br /> Ot 3 bio SVeet Number I Direction I Street Name C' / Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> LEW 0Frt ) Street Number Street Name <br /> CIN STATE ZIP <br /> CA <br /> PHONE#1 Er' APN# LAND USE APPLICATION# <br /> ( ) 36- OOoS .?Sd - 40 -1 5A - 7 -G-7 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEV �/V l/SYY` r� '�! PHONE# Q3 ' <br /> HOME Or MAILING ADDRESS ^ !9 • x I 1 6,B! 2,!5;-?0CITY !i( LO �/ 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 or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this applica on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST, <br /> T E nd FEDE WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MVANAGER ❑ O ER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of auth ization 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /NIT LV4 A At D9 L(lTAII?/c <br /> COMMENTS: <br /> 'Lp05 <br /> GO JNCt <br /> 0- <br /> ACCEPTED BY: O L(V G EMPLOYEE#: P 3 Z/ DATE: z 23�OS <br /> ASSIGNED TO: l7G 4Z'AF—j EMPLOYEE#: O/Lf G3 DATE: 2 Z-3 GS <br /> Date Service Completed (if already completed): SERVICE CODE:: S P I E: <br /> Fee Amount: - c((�S ec? Amount Paid j� �(0 5" -OZ Payment Date s <br /> Payment Type �- Invoice# ,.,\ d �p Check# P-�Ly� Received By: <br /> REVISED SED 101 17/2003 SVI OV <br />