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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> r" SERVICE REQUEST# <br /> Type of Business or Property FACILITY ID# 1 <br /> S oP - b71,p°I-7 <br /> - <br /> OWNER�OPERATOR �' CHECK If BILLING ADDRESS O <br /> _ _ <br /> FAcluTv NAME <br /> SITE ADDRESS �T� •� 5Z <br /> � <br /> LOD cit- <br /> - Cotte y. <br /> Straat Numbor Dlrectlon Street Mime _ <br /> HOME or MAILING ADDRESS (ff Different from Site Address) 7-001J11 t u pE 4i 1- <br /> Street Numberi2_ <br /> __S_trna Nxme - - -' - -- <br /> STATE e A ZIP 1912 yk <br /> CITY <br /> U(IC rA I,v h,c�Y>-_-__ <br /> PHONE#1 E'rr. APN# { LAND USE APPLICATION# <br /> f <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE 1 <br /> - , <br /> CONTRACTOR/ SERVICE REQUESTOR- �. <br /> REQUE=STOR -TSA C `.� CHECK if BILLING ADDRESS <br /> MI GK'�lE t✓ 'V` L <br /> - PBaNE# � -.4 .. .. EXT. � <br /> a <br /> BUSINESS NAME [�y� I C• Slo I�OZSO <br /> HOME or MAILING AD0119SS <br /> CITY STATE ZIP 1�SD1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 'L <br /> or activity will be billed to me or thy business as identified on this form. <br /> IBJ <br /> L also certify that I have prepared this application and that't � work to be performed will be done in accordance with all SAN.JOA�� FNT <br /> p C E'.. <br /> COUNTY Ordinance Codes,Standards,STATE and L laws. <br /> j. APPLICANT'S SIGNATURE: DATE: . .� ! - - vey Z 20 t <br /> ` wv,�frF�/� E �o�ouf <br /> ti cou <br /> PROPERTY/BUSINESS OWNER❑ :IJATOR/MANAGER ❑ OTHER AUTHORIZED AGit Ni <br /> f If APPLICANT is not the,BILLINGPAR TY.proofofauthorization tosign isrequired Title oFc�4��gq ' <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 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 /> r TYPE OF SERVICE REQUESTED: L r� <br /> 19� C L_ _ <br /> COMMENTS: 'Tar N A <br /> Td: rsC�1 r7 pA R ?-ipr.! Wf3 1 1 S I L to-'r(+lam,��J i, 1crti:r4 r C i4 C f S i':i <br /> >~o n,ca G•v <br /> )A�Ns 5Lc6Mffl-e <br /> AcCFPTED BY: T f� es cV DATE: _ f <br /> ASSIGNED TO: �ryu�� EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'Z PIE: <br /> (�p <br /> Fee Amount: ZS`r S� Amount Paid j Payment Date <br /> i <br /> Payment Type CT C ti5,,,: Invoice# Ch k# S'l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />