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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR ri <br /> CHECK If BILLING ADDRESS <br /> J i Y� OYYI i i'l �-� aL <br /> - <br /> FACILITY NAME <br /> SITE ADDRESS 33�iw 2 <br /> 3'b-?Co 33510 ' S acs-4-��- �d Trac Fc)530�- <br /> / Street Number Direction Street Name C Zi Code <br /> M. <br /> R If Different from Site Address <br /> HOME Or MAILING ADDRESS { 1 5, r <br /> �S <br /> 337 ZO Street Number Street Name <br /> CITY <br /> S <br /> TATE ZIP <br /> TrzL CA q5 304 u <br /> Ext. LAND USE APPLICATION <br /> APN 9 <br /> PHONE#t , <br /> :s <br /> 7-4 Z Z <br /> t 1 7-779 Z 255-1 Ids 7 3 rJ <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 1 I U <br /> s <br /> CONTRACTOR/ SERVICE REQUESTOR =Y <br /> REQUESTORr�y • . CHECK if BILLING ADDRESS❑ <br /> C\J J•/lwiy'V� N[I <br /> b ? <br /> BUSINESS NAME PRO <br /> NE# Exr <br /> i dye m u k <br /> xw <br /> HOME or MAILINGDDRE FAx# � s <br /> po. 7-1 e0 {?v9r 33 -o <br /> cllY Sizip <br /> s <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sami. e <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> i <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,SIATE and F E L laws. <br /> APPLICANT'S SIGNATURE: DA'L'E: 7 —/3 71D 4 <br /> PROPERTY I BUSINESS OWNER Q OPERAT I A'IA GER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY proof Of allthOTiZation to sign is required Title r <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 available and at the same <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RCE1�'c4 <br /> � JUL 2 s zoo <br /> Y` �N <br /> i' 9 <br /> 3 � ��pEp/1RTME1N1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 4 <br /> ASSIGNED TO: b 1 y EMPLOYEE#: �J�j DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: t1, Amount Paid z 3� Payment Date <br /> Payment Type G� Invoice# Check# 3 1 Received By: <br /> EHD 48-02-025 SR FORM(G den Rod) <br /> REVISED 1 111 712 003 <br /> J1 <br />