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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> keiv-► I CandLi Sadi - 5K008 i as i <br /> OWNER/OPERATOR 1 <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS 7 Stree✓tNu2-'mber D� 'e-Is <br /> _ tn <br /> Direction trees Name <br /> ��/Z/-�C�ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) rj)b �' ,�-tient )cl id n/1 I ✓ <br /> G Street Number (� ,1 Street Name rf L <br /> CITYS , oL --/aoa& $T T ZIP l <br /> PHONE#1 (), P rE`xvT• APN[#� LAND USE APPLICATION# <br /> Ib6b 503 -•736 a.4 (- 530 - <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O n �Q W CHECK if BILLING ADDRESS O <br /> BUSINESS NAME VVV Q Can d I PHONE# EXT. <br /> 4is 405 --79 a3 <br /> HOME or MAILING ADDRESSq-00 A I n S1 . FAx# <br /> 1 ( ) <br /> CITY j�a I C i f STATE n ZIP C?4 O ' 4 <br /> ' <br /> BILLING A�`CJJKNOWLEDGE ENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL'fIt DL-•PAR'1'MEN'f hourly charges associated with this project <br /> or 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 /> CONN-I'Y Ordinance Codes,Standards,STA ':and FEDERAL S. <br /> APPLICAN'T'S SIGNATURE: / I Lj f (. <br /> PROPERTY/1111SINESS OWNER❑ ERA'1'OR/1NLtNAC OTIIERe\llTl101tl'LEDACEN'1' <br /> If APPLICANT is not the BILLING PARTY.prnojof"uthorization to sign is required Titt <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 COUN'T'Y ENVIRONMENTAL HEALTH DFPARTMEN'r 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: W � '0 <br /> •1 <br /> COMMENTS: <br /> F10 FNr <br /> PyOkf- b �r &u�4 C-U-t�Cl Ott ,VF6 <br /> ,94NJO -2419 <br /> ytc oNI)Vcov <br /> ACCEPTED BY: „/,/� �� EMPLOYEE#: DATE: / 7 EA,yR'VT,g4 <br /> V V l MFNT <br /> ASSIGNED TO: ` EMPLOYEE#: DATES / 7 <br /> Date Service Completed 0 already co leted): SERVICE CODE: 69c'-'/ IJ P I E: bpm <br /> Fee Amount: 1 SZ Amount Paid �5�7 Payment Date <br /> Payment Type � Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />