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SAN JOAQUII OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ._�� C-7L1/I G�-� fl i Y l S/o / � IL CHECK If BILLING <br /> LADDRESS❑ <br /> FACT ITY NAME 1�(l YYN <br /> 3.I–C_ S W-cy` I FFS O P S <br /> SITE ADDRESS <br /> yYl I Cr()�2 Ctl-;Kj L(� �'&xZ--t4 CR _,o t S�3! <br /> 000 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S'S �'-O�In�Y µ{icQ ta-Yk Fl-£ S£�> treet Number Street Name <br /> CITY STATE ZIP <br /> c.tt-rrrJ CA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZM) 4-(, g - 31 Cr, <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 O-S-C-1 <br /> 0 <br /> 4 ucy CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Le4a--� P41 S ? <br /> HOME or MAILING ADDRESS FAX# 3 7 Z <br /> 2 3-7 0 qc 6-14 S u t-r- (z-C6) <br /> CITY L-�V� 1 STATE ZIP c7c52- `f0 <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 <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, STATE and FEDERAL laws. <br /> —2� <br /> APPLICANT'S SIGNAT DATE: � <br /> PROPERTY/BUSINESS OWNER❑ RATOR NAGER ❑ OTHER AUTHORIZED AGENT �(�( ['QIJ'tL77)lZ <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 propiMi <br /> the <br /> abovesite address, hereby authorize the release of any and all results, geotechnical data and/or environmenent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon aS it is available and att 1S <br /> provided to me or my representative. AUG 2 4 2012 <br /> TYPE OF SERVICE REQUESTED: gAN JOAQUIN COUNT <br /> COMMENTS: EPARTME <br /> �£la V kG€c79 <br /> ACCEPTED BY: EMPLOYEE M DATE:14 <br /> Z <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E: <br /> Fee Amount: 3 d.` Amount Paid �3`7S (� Payment Date v Z (� <br /> Payment Type / Invoice# Check# oZS R 5�— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />