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• '� SAN JOAQ*COUNTY ENVIRONMENTAL HEALTH I6ARTMENT <br />SERVICE REQUEST <br />Tyvq of Business or Property <br />ResmraA . <br />OWNER / OPERATOR <br />U -S. ]ME - L - 34SI' �sVA) — - <br />FACILTYNAME�wrPNeeAIto <br />t°r�'lr1r� <br />SITE ADDRESS Co rml il/t %%fil,/ � Rd 1 r <br />Street sNumber �l� 1 iDiirlWection' saeetwme �+f�• �(l <br />TY <br />r. <br />FACILITY ID # <br />/}HHOOMM^E MAILING ADDRESS/1(IIf Different from Site Address) f4 80�(�j �— <br />ifP <br />#1 EXT. <br />10/ - / / APN# <br />�Kil <br />SERVICE REQUEST # <br />CIECK If BILLMG ADDRESSX <br />Fm6v I <br />Zip Code <br />3 <br />LAND USE APPLICATION # <br />BOS DISTRICT LOCATION CODE <br />REQUESTOR <br />CHECK N BILLING ADDRESS <br />'V'(')v l <br />�S <br />BUSINESS NAME <br />deV k 0 33-61 > <br />HOME or MAILING ADDRESS <br />— �# j <br />FAX <br />99) PV -56,2 <br />CIT �.-a 0 <br />Zlp <br />STATE (7,4 <br />BILLING A.CKNOWLEDGEMENT: <br />I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAKIMr;Nl" hourly charges associated with tnls 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 m accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED laws. C <br />APPLICANT'S SIGNATURE: DATE:-7'Zt'Oq <br />PROPERTY / BUSINESS OWNERD OPERATOR / MAN 0 OTHER AUTHORIZED AGENT U <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 enviro e�ite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i rZr® the same time <br />a..a:_.,_ QC <br />It is IOVIUCU Lo Die V1 111 lc <br />TYPE OF SERVICE REQUESTED '��� <br />G JLLLdLxvc. <br />Weo7dAl <br />ra11100 <br />GOVN� <br />COMMENTS <br />SAN SpA ONME{4SA�N. f <br />, <br />LAN OP <br />N <br />APPROVED BY: <br />EMPLOYEE #: <br />DATE: Q <br />ASSIGNED TO: <br />EMPLOYEE #: <br />U DATE: <br />Date Service Completed (if already completed): <br />I SERVICE CODE: 3 1 PIE: <br />Fee Amount: <br />I Amount Paid ( �� <br />I Payment Date O <br />Payment Type ✓ <br />Invoice # <br />Check # 3 0 a <br />Received By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORK OVO.L <br />