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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /X100 L47 <br /> OWNER I OPERATOR <br /> CHECK If BILIJNG ADDRESS <br /> FACILITY NAME l pr <br /> SITE ADDRESS 1 ? / O1 �Q,14,S\�:1� F-C��4O Li%oOie4 /JZ�J ro <br /> Street Number Di tion Street Name city Zip Cody <br /> HOME or MAILING ADDRESS (If Differentfr�o/m Site Address) <br /> Y• l:J��X 7 • Street Number Street Name / <br /> CITY / t Sn Zip gSL3 W <br /> PHONE#1 C•, �T' APN# LAND USE APPLICATION# <br /> ( 1 "S-llo - a 7 9 "04- <br /> PHONE#2 EKT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> ��OOI • II��-A �I CHECK If BILLING ADDRESM <br /> BUSINESS NAME ( 1 1tD�j,-) r"I I M o Ir I PH( 70# ,53 v- 6 6 <br /> HOME* LING ADDRESS L �'1 FAx# <br /> Ila0 . rix 2180 (Zoy ) 37q - 67 2-3 <br /> CITY / 6Z STATE CqZIP y'SLL/I <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 FEEDD'Et`RAL laws. / <br /> APPLICANT'S SIGNATURE: Yui Il/1� DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not 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 and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE RE n <br /> COMMENTS: R <br /> SAN JOAQUIN COUNT/ A 66ee)77C <br /> ENVIFiOMENTM ((oOn//A) <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> O <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <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 />