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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-�l livy R-w1 4 (; tUwoq--� <br /> OWNER/OPERATOR V/y�_ „ ) ('�I ^ n <br /> r►«J 1" � J 11/1 CHECK If BILLING ADDRESS <br /> FACILITY NAME Ml9 MWS <br /> C'/1AJROl� <br /> SITE ADDRESS t'`I I dt'lull l ' �� T q la� <br /> Street umber Diredlon Slreet Name l�V CIJt JZi Coae <br /> HOME Or MAILING ADDRESS (If Different from Site Address) '1/_ "1 O LA MUM X- <br /> street Number street Nam* <br /> CITY � ,t �D`�' STATE tt <br /> /1/� ZIP q S a <br /> PHONE#I iv IJ[l APN# LAND USEAPPLICATION# <br /> Q) X�b <br /> PHONEt#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `, I ^n CHECK if BILLING ADDRESS <br /> BUSINESS NAME I PHONE# '-o E' <br /> HOME or MAILING ADDRESS l'` / �� 1 IPQA ,rip (Ax# ) /y <br /> CN <br /> CITY 1 b�—rl �1 lfh' STATE /1 A_ ZIP <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 ENviRoNMENT.AL 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,STATE and FED ALIa yS. <br /> APPLICANT'S SIGNATURE: DATE: d 6J' (o1I <br /> � <br /> PROPERTY/BUSINESS OWNERca, <br /> �Iqq OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ'APPLICANT is not the BILLING 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 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. nn'^^r1CCI <br /> TYPE OF SERVICE REQUESTED: W�4w� Ort E/ccy <br /> COMMENTS: CD <br /> AUG 18 ZO <br /> C`^�� O( ��ne�sl�rp S EN/AQUINO ?1 <br /> y l I HEgLTH pEPARrMENrY <br /> ACCEPTED BY: Q I EMPLOYEE#: I g DATE: <br /> ASSIGNED TO: EMPLOYEE#: 10 I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:'V(/v <br /> Fee Amount: Vu I Amount Paid �Sa Payment Date S <br /> Payment Type V �G- Invoice# Check# 1 Zq b Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />