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SAN JOAQL_ �OUNTY ENVIRONMENTAL HEALTI. —EPARTMENT <br />SERVICE REQUEST (OsTod� <br />Type of Business or Property <br />L LULU 8 <br />/t /\�/j � �.y - / / i �Vl <br />/ l <br />iHt Y2`r'/I�rL{'L r(�f/T <br />FACILITY ID # <br />�- `{ v <br />�J (��r <br />BUSINESS NAME UJ�,iA7/ /i' C <br />SERVICE REQUEST # <br />OWNER I OPERATOR <br />WNER/OPERATOR/S S +r^E <br />l�-5 <br />L—vq LL V jI <br />CHECK If BILLING ADDRESS <br />FACILITY NAME /// fMf—I�4 <br />STATE ZIP 934 <br />TE OGRESS <br />SStreet Nmber Direction <br />F�R'pf/O <br />I Street Nam r <br />Ci <br />Q <br />1'5z la <br />HOME Or MAILING ADDRESS (If Different from Site Address/ <br />Street Number <br />st.. <br />CITY <br />STATE ZIP <br />PHON,�E#1ExT. <br />(am 4?2' 2-11 ' <br />APN # <br />��QU <br />LAND USE APPLICATION # <br />PHONER Exr. <br />( I <br />ASSIGNED TO: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A , 1 t i , )` <br />/t /\�/j � �.y - / / i �Vl <br />/ l <br />iHt Y2`r'/I�rL{'L r(�f/T <br />n CHECK If BILLING ADDRESS <br />I^r\ <br />�J (��r <br />BUSINESS NAME UJ�,iA7/ /i' C <br />COMMENTS: <br />P <br />�� .� <br />HOME Or MAILING ADDRESS,? <br />DDRESS (/ A �T• <br />V I <br />F <br />CITY y r.IF�. <br />STATE ZIP 934 <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 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, STA E�"T�FqTn ER 1 <br />APPLICANT'S SIGNATURE: C/LOtG DATES:: <br />PROPERTY / BUSINESS OWNER OPERATOR / MAN GER ❑ OTHER AUTHORIZED AGENT t2� (`001VTKA 1. / "r\ <br />If APPLICANT is not the BILLING PAR Tr 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 reoresentative. <br />TYPE OF SERVICE REQUESTED: <br />PAX10FT <br />COMMENTS: <br />RECEIVE <br />2012 <br />AUG 14 <br />EN�RONMENTAL- <br />HEALTH OEPARTMEN <br />ACCEPTED BY: <br />` <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Z <br />P 1 E: p <br />Fee Amount: d` <br />Amount Paid-* SN _0-0 <br />Payment Date <br />(12 - <br />7Payment <br />Payment Type ✓ <br />Invoice # <br />Check # L f2-2—�;— <br />Received By: �L_ <br />EHD 46-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />