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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST /� 05y0015�L <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �m-D Nlo�ol\e Wc. '� 2�J SI,SU3 <br /> OWNER/OPERATOR �4^',fie , �r �� ^n <br /> 0U6 U� _1L CHECK If BILLING AODRESSO <br /> FACILITY NAME 14 -45 C— ( O,j_, J� <br /> SITE ADDRESS�� <br /> Sreer Number Direction I/ S / y e � vvlC Npsa ob <br /> Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site/Address) J .�Y / <br /> �N1 S E UY'e C fG l Street Number ( Stree(t Name <br /> CITY ST�AI ZI���D <br /> Su �1nuS FF <br /> PHONE#f Ez ' APN# LAND USE APPLICATION# <br /> (5I()) 9) - 819 7 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �) i <br /> ,llll ll WO <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 `1 Ll _ GS 1 O O PHONE# x' <br /> E ' <br /> HOME or MAILING ADDRESS V`� FAX# <br /> h�IS ( ) <br /> CITY (Sry I/ lnS STATE ZIP /1/n <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 <br /> or 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 all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards, TE and FEDERAL laws. 6i;ftr <br /> XAPPLICANT'S SIGNATURE: 'I�,- DATE: �EC/EAVED <br /> RrLJ <br /> PROPERTY/BUSINESS OWNER❑ OP ATOR/MANAGER OTHER AUTHORIZED AGENT❑ `r f / y iy� <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to Sign is required 4%JOA Td-(le s <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator DIBg� N at the <br /> es <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environm 09f1 sment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the sante ime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: \J fit . <br /> wwau <br /> COMMENTS: n o f or y et m Q� 1 (o ry� D� <br /> V `LL \1 <br /> YICSAN <br /> HJ QUlly` `a�9� D�I�Qj1/LSVIt Y f yHDNME NTu <br /> ACCEPTED BY: l..I ~9l IAIn C EMPLOYEE#; r// X�U )DATE: <br /> ASSIGNED TO: 0, J EMPLOYEE#: ��VVV DATE: <br /> Date Service Competed (if already completed): SERVICE CODE: P I E: �(J <br /> Fee Amount: Amount Paid (r>�� Payment Date ;Li 21C) <br /> Payment Type h Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />