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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � a2©off—�98� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSM— <br /> Joh^ Vo vx <br /> FACILiTYNAME C'e` <br /> SITE ADDRESS Y3�-q C l i vv 0,�75fteat <br /> . ,a-� 971nCoe_Street Number Direction ame ZI Ca eHOME Or MAILING ADDRESS (it Different from Site Address) 0-v Numher street Name <br /> CITY STATE n A ZIP qs 33(0 <br /> PHONE#1 ExT, APN# 7.45 —1 ie D-31 t- LAND USE APPLICATION# <br /> (z,vi) R(u - S'�2� cAl) ��,.+rm -4�#S-I(do—2-`r vv1�3 raq� <br /> PHONE#2 EXT. B DISTRICT LOCATIC3(t CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A �aC G� CHECK if BILLING ADDRESSE] <br /> f's PHONE# I ExT. <br /> BUSINESS NAME <br /> Ll V$ Oojc,. �A�'.J L✓OY11Nb¢wi'c� - Zvi3,(v9 -O 3:f T <br /> HOME or MAILING ADDRESSA4.0-+ tAj. Qak 1'�q) 3�R- 5 <br />' <br /> CITY Lvou STATE L+ IN ! ZIP IR S-X40 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S.SIGNATURE: DATE: _!^5I 1 q6cr <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER OTXMR AUTHORux,i)AGENT 0 <br /> If APPLICANT is not the BILLING PARTY,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 av ilable and at the same time it is <br /> provided to me orzany representative_ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 7 r O 4' �� 3 a/1NU�N� fJC/ RCE vED <br /> MAY r 8 2 <br /> SAN J0PQUtNN Y <br /> Ci�P <br /> T NV4Fi0NPA TMENT <br /> ACCEPTED BY: QLI v EMPLOYEE: 2, DATE: S C t'� <br /> ASSIGNED TO: EMPLOYEE : �( r DATE: 5-' ?Thh a <br /> --r 5t'oi�pLt-c,pS <br /> Date Service Completed (if already completed): SERVICECODE: 3 i`t PIE.��� <br /> Fee Amount: 4 2-3,P Amount Paid 0, 0 C7 Payment Date Q <br /> Payment Type ✓ Invoice# Check# 3 t7Z Received 13 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REMISED 11117/2003 <br />