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SAN JOACII-t— COUNTY ENVIRONMENTAL HEALTH L ct'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cl Fk61°1557 SV6 7 R E 7 <br /> OWNER/ E <br /> 0� TOR IA q �7 <br /> ,/ I�tJh�V CHECK If BILLING ADDRESS <br /> FACILITY NAME Car�ra(� U �ln/ /V -4111 <br /> SITE ADDRESS `1/ <br /> $treat Numher Oirectlan i r �r '$treat m0.1 <br /> HOME or MAILING ADD`REES"S (If Different from� Site Address) <br /> VS� 'IrC�kfa A Street Number Street Name <br /> CIS iak frn STATE <br /> ZIP ZO / <br /> PHONE#t EM' APN# LAND USE APPLICATION# <br /> (90 ) 600 9(o Z Z 1 (09/33';: � <br /> PHONE#2 E"T• BOS DISTRICT LOCATION CODE <br /> ( ) 6 d <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .e r� <br /> O CHECK if BILLING ADDRESS <br /> BUSINESS NAMECta3 PHONE# ' <br /> 5i 0 -7,91Z <br /> HOME Or MAILING ADDRESS FAX# <br /> 3o G of ( ) <br /> CITY S� n STATE�.t zip 7 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Of project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this project Of <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard=— l/ <br /> and AL laws. 2 <br /> APPLICANT'S SIGNATURE: DATE: 1161 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessmen ,ormation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pfOQVl9_.4orm <br /> my representative. er CN71 <br /> TYPE OF SERVICE REQUESTED: r <br /> 144 <br /> COMMENTS: o <br /> 0COA <br /> HFENVI�QU <br /> OUIV <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED T0: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: DPIE: <br /> Fee Amount: Amount Pal Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />