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SAN JOAQUII .OUNTY ENVIRONMENTAL HEALTH JPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / <br /> We S, 600+ �dVr� JS CHECK If BILLING ADDRESS <br /> FACILITY NAME 7 (' <br /> SITE ADDRESS �OS eIM 1• N)GWI�CSI �S-2?� b <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS If Different from Site Address) If Cp__.�-o�..�(� D Y <br /> AStreet Number �'l Street Name <br /> CITY / Q I A Lm k $TATE ZIPgN 2 3 <br /> PHONE#1 (� EXT. APN# LAND USE APPLICATION# <br /> (1-14 ) bio- 5,400 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 11 <br /> ( ) <br /> �J) CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> T L L M 'i 49o✓' FDv'C2 , 1&4C- CHECK if BILLING ADDRESS <br /> L3 <br /> BUSINESS NAME 16� LI ySe ,10-a ' Sf et- f PHst' 6i��' P� ExT <br /> HOME or MAILING ADDRESS FAX# O <br /> (%Z) 41 Z�---f (3 <br /> CITY PC STATE G'/� ZIP gort1I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, oper'ator 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 /> 1 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ( �'�Z��4 <br /> PROPERTY/BUSIN ESS OWNER OPERATOR/MANAGER ❑ OTHER AUTIIORIZEDAGENTA3J k6n±'nI ��'R�G� <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required/' Title <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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. T <br /> TYPE OF SERVICE REQUESTED: l/` % ' - RECEIVED <br /> COMMENTS: �oOA <br /> JUL 2 `s <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: i ftp EMPLOYEE#: DATE: —7_1C. <br /> ;?j <br /> t <br /> ASSIGNED TO: EMPLOYEE#: U 3 _j <br /> eteDATE: <br /> Date Service Compid (if already completed): SERVICE CODEI: rr I q P!E: 3 t;i <br /> Fee Amount: AL 7 ' �,�; Amount Paid a7q Payment Date 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />