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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH CLcI>ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> !Fcorkliadiotz SR Co--WS5 <br /> OWNER/OPERATOR ///��� r <br /> 5h6j Y—o),i pl^y rI /1 HECK If BILLING ADDRESS <br /> FACILITY NAME N^ ( 1n"A1 r' /" Lr/l r V' I I I��l� 1� r <br /> SITE ADDRESS�`� P L/q'//�� 1 }1/,I/' (•DI S'F S 1'�C r- �(� 1`1 Q7�O� - __ <br /> St et Number Direction w•I I ,`"�� Street Name CI L ZipCode <br /> HOME Or MAILING ADDRESS (if Different from Site Address) N /. 11 I ,f Q ro S 3PI(�,r01 <br /> 14 52 Street Number W Street Name <br /> ClIS�� STATE ZIP e) <br /> PHONE#1 EZT. APN# LAND USE APPLICATION# <br /> (ao�p 13- 4210 ILI�230o3 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) OC) I O�1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ly <br /> Met <br /> 9 O CHECK If BILLING ADDRESS <br /> BUSINESS NAME c-(f' ( NV-9 <br /> Lf^1 ( PHONE# Exr, <br /> MOMA )� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZI 05 <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANTI OtffleBILLINGPARTY proof ofauthorization tosign isrequired 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is provld9d t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I O — Fcccj Vig-nicAp I _ <br /> COMMENTS: <br /> V� Yl(ci� f1szW cwntj 3py <br /> 0��qT RU,D <br /> hOF qR���<H <br /> ACCEPTED BY: fl , EMPLOYEE#: DATE: <br /> ASSIGNED TO: o EMPLOYEE#: DATE: 7, I I 1III <br /> Date Service Completed (if already completed): SERVICE CODE: U 60 1 PIE: 1 JQ 0, <br /> Fee Amount: $ 15 2• Amount Pai - �a,(�it Payment Date r3 /4 <br /> Payment Type Invoice# Check# Receifed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />