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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S C)c)S312 <br /> OWNER/OPERATOR <br /> N-1 lel r vC j} E Zl L CHECK If BILLING ADDRESS D <br /> FACILTYNAME SLLbv-way FYc,v�ckt�se C A# 6-72.°16 <br /> SITE ADDRESS 1 6 0 1 S L-6 W A Y S a C Y ayn Q v-Fa -'rA L'04' g S z Li a <br /> Street Number Direction I Street Name Cfty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) E 3 O W T;;�1--i ek v—Av-, ak v e— <br /> Street Number Street Nami- <br /> CITY � _ STATE (� ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (a.v9 ) '3 ki 6 -- as W8 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ta,�L) ) 66 6 - b 6 9 1 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A r� <br /> '`} I N I V C D C.�-7��+L CHECK if BILLING ADDRESS <br /> BUSINESS NAME EOL c gA L I IJ C- DSA S�wa F�r�S PHONE# E'er <br /> a '� <br /> HOME or MAILING ADDRESS 2-3o <br /> � FAX# <br /> 6 3 o vj 6Lte k vv-qv-, rive— <br /> CITY <br /> L;2 <br /> ive— <br /> CITYL;2 16-D P STATE Grp ZIP cis-'13-0 <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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. m <br /> APPLICANT'S SIGNATURE: DATE: ! —7 2 <br /> T� <br /> PROPERTY/BasiNESs OWNER® OPERATOR/MANAGER OTnERAuTHORIZED AGENT❑ <br /> If APPLICANT is not the B1LLflVG PARTY•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 JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: YNj <br /> COMMENTS: 'VA' <br /> JAN 0 D <br /> SA IV joZ�21 <br /> kEA THRD�+M�CpUIy/T <br /> DEpARNTq� Y <br /> ACCEPTED BY: D EMPLOYEE#: DATE: <br /> ASSIGNED TO: )(ln\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Q 1 P I E: ` O� <br /> Fee Amount: ,�2,oo Amount Pai Sv7.�� Payment Date r 2 f <br /> Payment Type �[� Invoice# Check# Received By: <br /> EHD 48-02-025 P I " SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />