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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 61Z06 Coo*7q <br /> OWNER/OPERATOR <br /> m1Cn���' fi �`��� • Z T H �.�Lt PS CHECK If BILLING ADDRESS <br /> FACILITY NAME FJOI`L) PS PJZ0eC;XTy <br /> F f <br /> SITE ADDRESS <br /> �T�4:EfR-����i2:1� /tC.ArvK P a 9 S Z.3 0 <br /> Street Number Direction I Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 0. 3oK tlaS$ MD6 - �z-1 o w. t, 01DD$l-IbG'E <br /> CITY y Street Number Street Name <br /> STATE. ZIP_iC—ZTZ <br /> PRONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, 130S DISTRICT LOCATION CODE <br /> ( } <br /> CONTRACTOR / SERVICE REQUESTO.R <br /> REQUESTOR <br /> •�B� GLL7 CHECK if BILLING ADDRESS�I <br /> BUSINESS NAME UVC 0004. &r,dir,Nvl Ii-0NrAE" f4.L PHONE# EXT. <br /> - (ZaZ13ca9-a3�S <br /> HOME or MAILING ADDRESS 401 W.�� w• oma- ST . <br /> CITY L.ppt STATEZIP 41 <br /> R Lef D <br /> BILLING AC>E<:NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 ti,,,ork to be performed will be done in accordance with all SAN 30AQUfN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE* DATE: <br /> PROPERTY t BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTnFR AUTHORIZED AGENT LY {- <br /> 1)'APPLICftNT is not the BILLING PRRTL 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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me of my representative. <br /> TYPE OF SERVICE REQUESTED: ?'CJIEWaV�t- <br /> COMMENTS: 7/-2-5? <br /> 25? / � RECEIVED <br /> JUL 13 2010 <br /> SAN JOAQUiN"COUN3Y <br /> ENVIRONMENTALAW�HDEPARTMENT <br /> ACCEPTED BY: O C- EMPLOYEE#: Zr DATE: -7 If 3 Ir 0 <br /> ASSIGNED TO: L4SA tt EM I A)P- EMPLOYEE#: (, (' DATE. 67- 13-10 <br /> Date Service Completed (if already completed): SERVICE CODE: 3 te� P lE, �/ 03 <br /> Fee Amount: 2- 30 00 Amount Paid /7,6 Payment Date Q�P <br /> Payment Type Invoice# Check# .Q Re eive"y: <br /> EHD 48-02-026 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />