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(p � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ✓—QST �le-I*NT- S�z oosl' -�Z <br /> OWNER/OPERATOR\ A f_.p� <br /> JVA 0 � /'"A I UNSO� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Q , T <br /> 2ID Street Number Direction 7 treet Name Ci ZipCode <br /> HOME or MAILING A1DDRESS �If Different from Site Address) <br /> I I 17�2"i Street Number Street Name <br /> CI"Ca, bOo-ro H IU-5 C4\ C�5T6 2 STATE ZIP <br /> PHONE#1 ERTAPN# LAND USE APPLICATION# <br /> 0 ) 502- 521 2q1 - 530- NO - 00c) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR�Wl1Z a <br /> uV� CHECK If BILLING ADDRESS <br /> BUSINESS NAME1��. ^ / p NE# E.T. <br /> C A OSILW lb <br /> HOME Or MAILING ADDRESS FAx# <br /> vtz ( ) <br /> CITY t�A vowv o � �C - �� '�(r 2„ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersignedproperty 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 forst. <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. C, <br /> APPLICANT'S SIGNATURE: �+�— " Yv(b DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Iff <br /> If�APPLICANT is not the BILLING PARTY proof of authorization to sign is required Til/e <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. p <br /> TYPE OF SERVICE REQUESTED: T AVI OWL <br /> COMMENTS: lJ# jI 9 v„ ��„j J � <br /> eoqo 9 ?p19 <br /> ACCEPTED BY: Y,YVl,�v1Q,(/IEMPLOYEE#: DATE: <br /> ASSIGNED TO: �'"� /yl I/I EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: S2 P 1 E: O <br /> Fee Amount: —I SW i Amount Paid 4 Payment Date <br /> Payment Type I 1 ' Invoice# Check# 310 Received By: <br /> EHD 48-02-025 - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 IS <br />