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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DP - 19 L66si 4LAvri i- 52oa q r3 R <br /> OWNER/OPERATOR <br /> n/E / SA N L L fy pP EIV © L L c CHECK If BILLING ADDRESS I� <br /> FACIurYNA <br /> C TS OAK 1O EsTgT� <br /> SITE ADDREA6 3;ZSS �/�y�4 �� n <br /> street Number Di_'Non SfmtNa ¢ L A17 S 9W2,O <br /> HOME or MAILING ADDRESS (If Different from Site Address) c L cove <br /> Set Number <br /> LPHONEM <br /> TY // trestre¢t Name <br /> STATE zip <br /> Ex. APN# 2 <br /> ) 2-7 <br /> t -,q,;..2 <br /> ^� ^ LAND USE APPLICATION# <br /> PHONE#2 ea— O( a` EXT. 62/ ��O^�� �� " 12-49'14�'t -O.?-56 <br /> ( ) BOS DISTRICT LOCA DON CODE <br /> ,_ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REgUESTOR <br /> Q M 44/JSGr 6CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr. <br /> CWZF o1/su c 7— & <br /> HOME or MAILING ADDRESSFAX# <br /> o • k3oK 3 q�I- ( ) z59e <br /> CIN 4--42 STATE <br /> irA 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 applicati and that the rk to be performed will be done idaccordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT FERE <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER UTHORIZEDAGENTjCI\ <br /> If APPLICANT is nal the BILLINGPARTr Proof of authorization to sign is required <br /> 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: All r <br /> COMMENTS: <br /> �� 1—cct �� E7P��i� ��lz�c ="��•j�pOS <br /> FAN0N`MJE"tIH1E <br /> EPIYP <br /> ACCEPTED BY: 6. OLi(/Er/LA' EMPLOYEE#: <br /> 03 _I DATE: O3_ (_ps <br /> ASSIGNED TO: �ti(� A— EMPLOYEE#: 4j`3(o(o <br /> DATE: EJ3�D/ OF <br /> Date Service Completed (N already completed): PIE <br /> SERVICE CODE: V <br /> `// C,j'2S : 102 <br /> Fee Amount: T(OSd 0 Amount Paid —` Payment Date �� r <br /> Payment Type Invoice# Check# <br /> p�qq <br /> x Rectlived By: <br /> EHD 48-02-025 541, 5—T <br /> /A) <br /> REVISED 11!17/21103 (J_ �- �—I�nI/VL SR FORM(Golden Rod) <br />