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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ac ?,lcu�,o v; 14 - 04 's"P30C)OE <br /> OWNER/OPERATOR {� rr�� <br /> 1-I(^`-1 AN 4%�rl��ISG S7�J , CHECK If BILLING ADDRESS <br /> FAcILm NAME N(A r` <br /> $READDRESS <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SAME A5 ZATE Street Number Street Name <br /> CITY SAME As ,1T.r= STATE ZIP <br /> PHONE#1 F=- APN# ¢ LAND USE APPLICATION# <br /> ('� ) 7 3 -5310 CtiaoM� 6�a3- I -oto_ Pr d2.- )L <br /> PHONE IKL Em BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'WAl=1l E-R_ iF= G u i 1 j CHECK If BILLING ADDRESS <br /> _t, Fxr. <br /> BDSINESS NAME G 1v 1 ANG t,N�EQ PHR61 3 h f3_ S 7 <br /> HOMEor MAILINGADDRESS A1n �A�-1t � fILJ�ZA Ax#Y ) �;ft <br /> CITY LO'DNIO 11r'1 t' STATE ZIP952/4-0 <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: A DATE: O FJC)G <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT�ff C1YIL FtAC IQEi` - <br /> IfAPPLICANrisnottheBILLINGPARTYproofofauthorization 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 t0 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 /> TYPE OF SERVICE REQUESTED: "SUR-r'ACE: 107161) Rffrr I P.EVIEW <br /> COMMENTS: I)S y. 17 L PAYMENT <br /> RECEIVED <br /> JUN 72M2 <br /> SAN JOAQUIN COUNTY <br /> 3 0 PUBLIC HEALTH SERVIC S <br /> ENVIRCNMENF4L HEALTH 910N <br /> APPROVED BY: EMPLOYEE#: C DATE: rl O Z <br /> ASSIGNED TO: / , ��.��0 uL-�C' EMPLOYEE#: CFQ S DATE: D p7/6 <br /> Date Service Completed (if already completed): SERVICE CODE:a t PIE: <br /> O <br /> Fee Amount: pp Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5.02 <br />