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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE RiQUEST = <br /> Type of Business or Property FACILITY ID# pSERVICE REQUEST# <br /> S Iw� 5 <br /> 29 <br /> OWNER I OPERATOR Y <br /> CHECK If BILLING ADDRESS. ' <br /> FACILITY NAME L V J pp <br /> SITE ADDRESS ( 3s ( )_ �ANd�N �D ft�Q M�J Q52Z0 <br /> Street Number Direction Street Name Ci Ztp Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2.3(71) 3618 - S76, � OO7 _ISo- l3 CA - C&— Jc(7L� <br /> PHONE#2 E T. BOS DISTRICT LOCATQN C06E <br /> I ) [� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR R( C ` V Vt <br /> 'r��� � I I CHECK If BILLING ADDRESS <br /> BUSINESS NAME �-{� PHONE#ZpT' <br /> oo -36 a -66 <br /> HOME Or MAILING ADDRESS FAY# <br /> -323 W . EL ( ) <br /> CITY STATE CA <br /> ZIP S 2-4c) <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 e,work to a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA aws. --7 <br /> APPLICANT'S SIGNATURE: /!/fes DATE: t 7- z-3 ' O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 ap{),ryf IDe time it is <br /> ED <br /> provided to me or my representative. I <br /> A(T V ED <br /> TYPE OF SERVICE REQUESTED: _�l O t L S Lc t 7-);76 t t_L S lu 6J <br /> COMMENTS: <br /> JOAO JIN COUNTY <br /> o MSAN RO <br /> HEAtNMFNTAL <br /> NA DEPARTMENT <br /> ✓��� /O� i�..,�.,fj�. :�_ . .ter'i'IQ'^ <br /> ACCEPTED BY: (�V t {F/-f� EMPLOYEE#: 0 3'Zf DATE: / -2z Q <br /> ASSIGNED TO: M I N EMPLOYEE#: S 3 Wo DATE: ( 21`2-6107 <br /> Date Service Completed (if already completed): SERVICE CODE: S 2-Z PIE: e) <br /> Fee Amount: . Cl (0 LL) Amount Paid (4 b O C) Payment Date <br /> Payment Type �:' Invoice# Check# l 03 Received By: Q <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />