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uxlr uvtAYUlly %,vUiv1 Y C,iNVIROiNME(V'I'ALr1EAL-fHI)EPAR'I'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY iD it SERVICE REQUEST# <br /> W1NEIZ V1 NE )Z S�Oa5355� <br /> OWNER i OPERATOR <br /> CHECK IfBILLING ADARESSO <br /> FACILITY NAME <br /> WJE LAIVNF W/NE,e <br /> SITE ADDRESS I e .r,4 5T- 11,1A1,2r./E y /—,4 N,E <br /> L o�i 91 szwa <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Namellowft <br /> CITY 3 STATE ZI <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> A•4-o 7-44o su-6. 79'0 <br /> PHONE#2 ExT• BOS DISTRICT LOCA7?PDE <br /> [ limy) 360 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQl3ESTOR j� <br /> I/O AJ CHECK If BILLING ADDRESS <br /> BUSINESS NAME �7 PHONE# �T <br /> G/��S,�E �O/VSuGT A/< <br /> HOME Or MAILING ADDRESS FAX# <br /> Pa L30X 379 - <br /> CITY STATE Zip <br /> �3 <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 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 applic 'on and that the work to be performed will be done in accordance with all SAN JOAQtrN <br /> COUNTY Ordinance Codes,Standards,ST E and FED aws. <br /> APPLICANT'S SIGNATURE: <br /> OJ41 � DATE- 2- <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ AGER ❑ ER AUTHORizED AGENT <br /> IfAPPLICANT is not the B=LVGPAR 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 JOAQUN 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: �X�EDI TET) /V/TlZF7-ff G p,NC Sp .3 S J`u Eco/EuJ <br /> COMMENTS: /ho/e-s/ <br /> RUSH <br /> IIIL usiv <br /> 3V ` - _ 7 tuU3 <br /> SAN,10ACION COUNTY <br /> ACCEPTED BY. 0 L i U L( v-94 EMPLOYEE# �� ��FtTM1=NT <br /> DATE: <br /> ASSIGNED TO: f;-17 S C ,v-Q--D EMPLOYEE#: S7 q DATE: 3 -7��dY <br /> Date Service Completed (if alrea le d): SERVICE CODE: .S`>S ���— P i E G Z <br /> Pee Amount: 4"U 'p -5 LO <br /> -1 3 Amount Paid 1 s ` Payment Date <br /> , <br /> Payment Type Ce# Check# Received By: <br /> EHD 48-02-025 SSR FORhR"( oldet'Ftod) ' <br /> REVISED 11/17/2003 <br />