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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH 10ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 Iy Q 2 <br /> OWNER/OPERATOR JOSp CA e—`JS U�SpCtC,, CHECK if BILLING ADDRESS <br /> FACILITY NAME LAS C-��v��l�s # L I C 3o l �= <br /> SITE ADDRESS 3D S �Gti l(j/j-t'�l� <br /> Street Number Direction ` " treet Na e \Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 Z 2 Z W .t��a J�1� �•tiQ <br /> Street N b. Street Name <br /> CITY �J"1 ►%`' STATE � ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# l 1 <br /> (Ml) 2rl$ gq-1G1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR T -�-t <br /> �S e C��� t' /l✓) ye 4, CHECK if BILLING ADDRESS <br /> BUSINESS NAME �c �^ _LAI I �J /� � PHONE ,y,`�E <br /> HOME or MAILING ADDRESS 1 l ,, FAX# 1 �� <br /> CITY C c='\T STATE 0A <br /> ZIP 01 <br /> -SZCLA _J <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 <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 /> COUNTY Ordinance Codes,Standards, ATE nd FED RAL aws. <br /> APPLICANT'S SIGNATURE: DATE: off-2� �� 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ 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 environm tal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ,lp a time it is <br /> provided to me or my representative. � ,�'YnJ c <br /> TYPE OF SERVICE REQUESTED: I/_j I e c 1 r-y' F® <br /> COMMENTS: � �O <br /> (�1 n S�✓O,gQU `D <br /> H �1R /NCO <br /> �Tiyo pM��IJIy�, <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (k-) PIE: <br /> Fee Amount: 1 C5 Amount Paid k—, <br /> Fee Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />