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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> KOO LL -f q+-1 <br /> OWNER/OPERATOR ,J <br /> .'e <br /> 5 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITCy/Se�DDRE `/� � <br /> `� c)�Stmet Number Direction Strebt m)�X.IJ ` /� " C n Code <br /> HOME or MAILING ADDRESS (It Different fromASjIto Address) <br /> (�, 'vim t <br /> $tenet Number $tenet Name <br /> CITY � STATS ZIP C(�✓-t i <br /> PHONE#1 Ecr. APN# LAND USE APPLICATION# <br /> (2cli ) /6-7- 3 /- 07 <br /> PHONE#2 En. I `Z-15100 <br /> -r 51 00---r BOS�C LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ / ar <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME LI U 11�2y PHONE# .` —� ExT <br /> 1 -5 <br /> HOME Or MAILING ADDRESS (� K FAX# JL"/il. <br /> U (2c- ) 3 a-72- 3 <br /> CITY I Q1�1 STATE CA ZIP r]2 <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: 2 <br /> PROPERTY/BUSINESS OWNER❑ PATOR/MANAGER ❑ OTHERAIITHORIZEDACENT Pt1 luel- <br /> IfAPPLIG4NT is no e B1LL/NGPAR7 Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> PAYMENJ <br /> TYPE OF SERVICE REQUESTED: QC :5- j RECEIVED <br /> COMMENTS: <br /> lee 1� i� glow AUG 2 4 uO(o <br /> (�jQptrn> �LI�Gcf� Ile r-/10 6 SAN JOAQUIN CQUMI t <br /> Q(ZS(O(a �e.{ IKU� ENVIRONMENTAL <br /> l iJ p ,n,,.— HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �y <br /> ,,,441 7f! DATE: .©G <br /> ASSIGNED TO: �l EMPLOYEE#: "7 VV3 J f DATE;Q —VJ <br /> Date Service Completed (N already completed): SERVICE CODE: <br /> O P/E; <br /> Fee Amount: O Amount Paid �� Payment Date <br /> Payment Type Invoice# Check# /)1,9 Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED <br /> D 111111/17/2003 <br />