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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type nnof11Business or Property FACILITY ID k S.E�,RACE RE <br /> QUEST k <br /> !.V t Sl�W�" 1� J <br /> OWNER/OPERATOR _ <br /> KY_; t 4 CHECK If BILLING ADDRESS <br /> �t-v�c�e�rsv <br /> FACILITY NAME UA Z ` <br /> ^ It ` 7 <br /> SITE ADDRESS J V ✓� <br /> VJ 0-IV.Q. 'r- 1`.t� ��P SIS Ito <br /> Street Number Dlrectlon Street Name C ZI Code <br /> HOME or MAILING A RESS (If Different from Site Address) <br /> t <br /> 9tree1 Number <br /> CITY STATE ZIP <br /> V, o n <br /> PHONE#1 Exc APN# LAND USE APPLICATION# <br /> PHONE#2 En, BOS DISTRICT LocarloN CODE <br /> ( t s51- � 3 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Za n <br /> BUSINEss NAME PHONE# En. <br /> i 26• S7 7. <br /> HOME or MAILING ADDR SS FAX# <br /> " S— ors-z..r w (2tq ) S1l- 0z43 <br /> CITY D STATE CA ZIP — V <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speck 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 with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST.aO and FEDERALLlaws. <br /> APPLICANT'S SIGNATURE: /y) DATE:44 <br /> 7/��l/oZbcZU <br /> PROPERTY/BUSirrESs OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLicAt&is not the BILLING PxRn proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 JoAQtma COLnTy ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: y� /� ' 1 e <br /> COMMENTS: New "IIAldI� V'(Lr L `c"te-N� OR 13 <br /> 3AN1 <br /> (� d JOAQUI� CNE lTNpT <br /> MEpRFNT <br /> ACCEPTED BY: oL EMPLOYEE <br /> DATE: r(0 - :)-O <br /> ASSIGNED TO: 'iL, EMPLOYEE#: DATE: C --70- <br /> Date Service Completed (if already completed): SERVICE CODE: JJ Z P 1 E: i <br /> Fee Amount: Amount Pa 7�t o-z) Payment Date L-3/:Z--o <br /> Payment Type Invoice# Check# 107,Ss Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />