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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR F�t01�DI�S� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Dir9tuon Street Name L City zip Oatle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EKT• APN# LAND USE APPLICATION# AY <br /> ( - ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION d�'Obwtl <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR %JOAn, 020 <br /> REQUESTOR /p/pp��I� //i' C <br /> TV <br /> 1`nni i.�.,i , i'�I CHECK if i <br /> BUSINESS NAMEPHONE# ENT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 I I'I �P.RT(l�.l hVFra II ( ) <br /> CITY _ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL. I ICALTFt DEPARTTAENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fort, <br /> also certify that I have prepared this application and that th prk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandal'ds,STATE al '.1 wS. <br /> APPLICANT'S SIGNATURE: D,AIE: ;;7 '- L ' 1: <br /> PROPERTY/BUSINESS OWNEROPERATOR/MANAGER ❑ OTHERAurnoRizEnACEN'rlua AC,EPl1 <br /> /J'APPIlCANT is not the BILLING PART) 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. <br /> TYPE OF SERVICE REQUESTED: PLAN REVI L\Al <br /> COMMENTS: I'lall i::V ld;`A.1101 1IevAw 1'u In t=xishl'10 t urni eicj it It-]tall h'wHitl 8paue. Slow, Uf.CIit 111`I ll:q:lil IIIOILIdO <br /> sales Df c<nnmercia'ly orepaekaged iood Items NO food preparAo I Ol ro1151lmlpticorl to cit!;lll or. s;I'W <br /> 1 "- 1 .'.ew r►1iGhGiGI09vA/7 • 4Jrn <br /> ACCEPTED BY: lti�S e_a EMPLOYEE#: DATE: 1^ <br /> ASSIGNED TO: f— ttK—f 2_ EMPLOYEE#: DATE: _ •L'� ZZS <br /> Date Service Completed (if already completed): SERVICE CODE: S'�3 P I E. r�0, <br /> Fee Amoun rT bD Amount Pa- S it Payment Date FQ <br /> Grp <br /> Payment Type Invoice# Chleeck# /b ,23�, 1267 IReceiN;ed By; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />