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SAN JOAQL,t.J COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> it) 1� -'P �,s 1 �P00231�q �I��0luW�(0 <br /> OWNE\ /OPERATOR <br /> Y0001� -T(\V , CHECK if BILLING ADDRESSO <br /> i FACILITY NAME r <br /> SITEADDRESS 615L 6� I �GC(T-(C l�Ut �J�"`t✓\ /� b� <br /> Street Number Direction Street Name -cityZi Code <br /> HOME or MAILING!ADDRESS (If Different from Site Address) <br /> 6iS � N �� � � P�Cl 7 Avt <br /> Street Number Street Name <br /> CITY � 6CLSTATE C A <br /> ZIP <br /> PHON E)11 ��� EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 _ l IT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> YOe�K � \ 7C`��� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �U `J �u PHONE# � I b Exr. <br /> 5C•��(�bA P e s 6 6 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY CI` STATE ZIP <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 pert ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. j <br /> APPLICANT'S SIGNATURE: DATE: 3o / <br /> PROPERTY/BUSINESS OWNER E!f OPERATOR NA R ❑ OTHER AUTHORIZED AGENT ❑ C -C--O <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the W <br /> saMVPite�dlded to me or <br /> my representative. � r�. ,"`r <br /> REeEIVED <br /> TYPE OF SERVICE REQUESTED: Food S u l 11 n <br /> COMMENTS: JAN <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q. A I EMPLOYEE#: DATE: 3� n <br /> ASSIGNED TO: EMPLOYEE#: DATE: --�6 lY <br /> Date Service Completed (if already completed): SERVICE CODE: P 11: <br /> Fee Amount: 1-3q Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />