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SAN JOAQUV- OUNTY ENVIRONMENTAL HEALTT"`IEPARTMENT <br /> `-' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST/# <br /> OWNER I OPERATOR <br /> R A J B i R S►N G H CHIN/NA CHECK If BILLING ADDRESS <br /> FACILITY NAME CHH/AIA -r 9 LIG ^KA FAR K1/V 0 <br /> SITE ADDRESS 3552 W 7OSE/ �-' IT� f9VE. LA 7WROF <br /> Street Number Direction I Street Name I city Ziptl <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2 Lf 65 L/N4cd L-N g l.. V ED+ <br /> Street Number Street Name <br /> CITY TK A C y STATE CA ZIP q-5-376 <br /> PHONE#1 Ext' APN# LAND USE APPLICATION# <br /> (, wi X32 , 74y4 2y1 - 400 bg AA - 09oa/4� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> SERVICE REQUESTOR <br /> REQUESTOR C v K H 5 CI-1191-1,44- <br /> J CHECK if BILLING ADDRESS <br /> BUSINESS NAME C /-��� �,/ a L eNCv /Y lFe"'Cllt/ PHONE# :5-1 <br /> Ext, <br /> ze5/ <br /> HOME Or MAILING ADDRESS17 O 13 f'x 7 7 y y 2 (z&9) <br /> 9s7 - i -393 <br /> / <br /> CITYS To G/c To N STATE G !7 ZIP 9 52 6 7 <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. e� <br /> APPLICANT'S SIGNATURE:X kms` Leelr, ,,� DATE: - <br /> i <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: S/3/ems Q /L �j„�.s� PAYMENT <br /> RECENED <br /> �4fio APR 2 7 2010 <br /> SAN VOADUIN OOUn T'. <br /> ENVIRONMENTAL <br /> HEALTH DEPART MEHT <br /> ACCEPTED BY: EMPLOYEE#: DATE: O <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid 2�, Payment Date41g "/--/0 <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Gol en Rod) <br /> REVISED 11/17/2003 <br />