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Y ENVIRONMENTAL HEALTH DEPARTMENT <br />• SERVICE REQUEST = <br />Type of Business or Property <br />is CLS <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Lt r" <br />FACILITY ID # <br />T <br />Ems' <br />1 33 <br />SERVICE REQUEST # <br />'S" O S I S S9 <br />OWNER / OPERATOR <br />1- 3 a <br />CITY SVvc STATE e fi <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS�fPpn <br />Street Number Direction <br />Street Name <br />Ci Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CIN <br />ACCEPTEDBY: <br />STATE ZIP <br />PHONE #1 EXT. <br />(doci ) .moi q a -Lute <br />APN # <br />5� - <br />0,90-2-1 <br />LAND USE APPLICATION # <br />PHONE #2 Lo M p • CARt ark ExT• <br />(1W) C1r)a— o0aa <br />EMPLOYEE #: ; -2 U <br />BOS DISTRICT_CATION _,CATION <br />-' S <br />CODE <br />LO -T <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�"% % C O i..�. <br />�'(� Gc <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Lt r" <br />PHONE # <br />Ems' <br />1 33 <br />HOME Or MAILING ADDRESS <br />.A Lx) r <br />FAX # <br />(;oq) <br />1- 3 a <br />CITY SVvc STATE e fi <br />ZIP C S, X 5, <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 or <br />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. Q� <br />APPLICANT'S SIGNATURE: yk&2v DATE: O 1 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT r�-�� <br />If APPLICANT is not theBaLINGPARTY 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 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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: (�(.S 'j— rT <br />RECrilMEN r <br />COMMENTS: <br />AUG <br />9 2001 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENT <br />AL <br />HEALTH DEPARTMENT- <br />EPARTMNTACCEPTED <br />ACCEPTEDBY: <br />C) LL L i� l t <br />EMPLOYEE #: 49 3 Z-( <br />DATE: q .7 <br />ASSIGNED TO: <br />1()4- r 4 <br />EMPLOYEE #: ; -2 U <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: [ � <br />P / E: = 2_Kfa <br />Fee Amount: <br />.. <br />Amount Paid <br />��i� , <br />Payment Date <br />Payment Type <br />�/ <br />Invoice # <br />Check # �2� V9 <br />Received By: <br />EHD 48-02-025 SF Qi (`ofd n Ftod) <br />REVISED 11/17/2003 <br />