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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CCll3�� ,�,yT/ti y ellv✓'al L --'00 4-- DO 5 <br /> OWNER I QftnRAfTM <br /> r�,4JCH�CKIfBILLIN <br /> FACILITY NAME / ��L / ` // ✓ �_9G� !'✓ GA <br /> /j' <br /> SITE ADDRESS `2"To lJ�•f7H eezzle"O& f;tlLLCl�•/ �2D %C'!!� `1 I ;PS-? 7 7 <br /> Street Number Direction Street Name city Zin Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY „-.. / STATE « ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# / •..7 <br /> (.-90) 416k' - X 0Z 6 2 53 0 S O l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) l <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR , ` /CG <br /> `✓ CHECK if BILLING ADDRESS❑ i <br /> BUSINESS NAME u�� CNI �/®.�5� PHONE# ' <br /> Q Y � ,IG�ASi �o fG 6` _s'��' � <br /> H6w7£-Or MAILING ADDRESS �'Pa C) r�7r /G ( ,,, Bl) t44001t440011 7 e <br /> CITY /�.f7�i/" J /J / 6 STATE 4:54 fqZIP vt ZU 1 <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 /> i <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 /> I <br /> COUNTY Ordinance Codes,Standards,STATE and FE RAL flaws. I <br /> APPLICANT'S SIGNATURE: ��is� //(N' DATE: <br /> �d�7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �� �yd` C�`G <br /> If APPL/CANT is not the B/LLING PARry_proofofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORM.A.TION: When applicable,1,the owner or operator of the property located at the I <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. <br /> i <br /> TYPE OF SERVICE REQUESTED:_ <br /> COMMENTS: <br /> s;lam �/�6P <br /> ACCEPTED BY: EMPLOYEE#: L�pf�°� DATE: 7 <br /> ASSIGNED TO: ) c�Ll��Ca rile EMPLOYEE#: 't�f9 DATE: <br /> i <br /> Date Service Completed (if already completed): IVZ 91477 SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> i <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ` <br /> i <br /> r <br />