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06/12/2008 1�-:55 1 2094640138 ENVIRONMENTAL HEALTH ` PAGE 02/02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> �� �) CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 0 b�VLH M t T � R-'✓ 7�rK cW cli <br /> Street umber erection Street ame C{t n ZI Gode <br /> HOME or MAILING ADDRESS (If Different from Site Address) I �/L I �G <br /> o r G'q /� Street Number /� Sem Name <br /> CITY � � a Owe- STATE ! I-4 <br /> / 1 <br /> J PHONE#t EIM APN#, LAND USE APPLICATION 9 <br /> k2 0-0 � � z �;�, Ufa � 7��+ I ( s � <br /> PHONE#2 Err, BOS DISTRICT f 11 LOCATION CODE <br /> ( ) ( 9- <br /> CONTRACTOR <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BtLLIND ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> �SG�aN► �t t. r rJ C, y(6 3 ��— a a� <br /> 1 HOME or MAILING ADDRESS EO L- <br /> V/P Y f ( q/L) 3g - Oa <br /> CITY G STATE ZIPC 5--42 �i <br /> I3ILI.ING ACKNOWLED EMENT; 1i, the tuidersigned property or business owner, operator or. authlorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DPPARTME-NT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application.Kand t work be pezf alined�vi11 be done in accordance with all SAN JOAQUMN <br /> C1111NTY Ordinance Codes,Standards,STATEF and F awS. <br /> APPLICANTIS SIGN TUT : l DATE: / b '�'O g <br /> PROPERTY/BUSINESS OWNER El QrFRATOR/MANAGER ❑ OTHER AUTHOPT7..ED AGENT L10 ������jl� ��v,•/+t1(,�v <br /> Tf APPLICANT is nat the B1LLING Prt,RT1;proof of authorization to sign is required Title <br /> AU1NaR17 ON TO RELEASE INFORMATION: Wben applicable, I, the owner or operator of the property located at the <br /> above site address, hereby atiChorize the release of any and all resulis; gcoiechnical data a;,d/or environ,-ncntal/site a.ssessmcnt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTALHEALTI-I 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: j� �u I Twp r � � t �T'' �t- n ' + T c'?_�{'T� � C -1 � : •�[r ��� ��� E: <br /> COMMENTS: <br /> –7111f, � <br /> �6U4G <br /> JUN 2 3 nous <br /> SAN JOAOUINECOUANTY <br /> r-mvinnNIVI <br /> ACCEPTED BY: L)L l V�G 1 k� <br /> EMPLOYEE#' C% 3 2 t IEA li$ +'AR�M 2T3 u p, <br /> ASSIGNED T0: t - I�j y�JG �U S EMPLOYEE M L,(C, DATE: 2,3 U <br /> Data Service Completed (if already completed): SERVICE CODE: S F i!:: (o G Z <br /> Fee Amount_ -� Amount Paid � L4,q`p C, r) Payment late <br /> Payment Type Invoice# Check# ?4 Received By: <br /> EHD 4a-02-025 SR EOF M(Golden food) <br /> REVISED 1111712003 <br />