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e0 _IF _ <br /> H <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -Food �� <br /> OWNER/OPERATOR <br /> a CHECK If BILLING ADDRESS <br /> C\ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction treat Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ;gyp V,/q <br /> 3G1L1 5ea5GQI)e WagStreet Number yeuScdPe Sleet Name <br /> CITY Sirot.K+on STATE CSC ZIP C[5106 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Hog )-770- 6346 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I..U15 0e ICA 20Sa CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> 3qW SeaStAPe wdy ( ) <br /> CITY 51OL Kv0 STATE / ZIP 0/'�zD6 <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 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 1 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: wt's OC td f Oso DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILL/NG PARTY proof of autliorilation 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. A� <br /> TYPE OF SERVICE REQUESTED: `V � rEf r <br /> COMMENTS: -' O <br /> i <br /> �NVWO Q U/NC®UN <br /> ACCEPTED BY: V 11�I�/I/IA/I'� EMPLOYEE#: DATE: I�� ZI� -1 <br /> ASSIGNED TO: V• y EMPLOYEE M DATE: <br /> T V <br /> Date Service Completed (if already completed): SERVICE CODE: 1 O I P I E: tlov <br /> Fee Amount: S _ Amount Paid I a/ Payment Date 021 2(7 <br /> Payment Type Invoice# Check# Received By: 1u <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 .p��53 oogd <br />