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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c,SERVICE REQUEST# <br /> J K <br /> OWNER/ OPERAT10Ri v, o-1 StrC� D J , CHECK if BILLING ADDRESS❑ <br /> Xf <br /> FACILITY NAME LL-q' e�t)vw / L-L-). / I` G� <br /> SITE ADDRESS. Lf 02, E MlOI�J{t �Ul/SVtu SV��'v <br /> Stre¢t Numb¢r Direction Street Name ca, <br /> ZI Code <br /> HOME or yMAILI��N77G A DRESS (`If Different fromite SAddress) <br /> 6 6- Street Number Street Name' <br /> CITY n N STATE ZIP <br /> PHONE#1 En• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR D t , rR�p � T <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME n S�.r�� / PHOT E# <br /> ExT. <br /> v <br /> HOME or MAILING ADDIR`ESS 1 Y FAxx# <br /> 2_ S c--k I t ( ) <br /> CIN Wi -r-o STATE A_ ZIP 11 S-2-0 <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 /> I also certify that I have prepared this applicationr4nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standard.T, STATE 'EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I 7777 T a LCA <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the Bl NGPARTY proof of authorization to sign is required Titre <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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assoon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -r—o Ply n C vxa�I� <br /> COMMENTS: <br /> afivSav►du div � yahoo • cc tit *pk <br /> 2 <br /> 2�PGh�U✓l�(� 1�1�i1J1S c �wt�P) (�J''f' tiE` oR/V, c U�2 <br /> ,l1An <br /> ACCEPTED BY: VY� EMPLOYEE#: DATE: ��, � T <br /> ASSIGNED TO: . G EMPLOYEE#: DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: C32- P I E: tool <br /> Fee Amount: L IGI/ i Amount Pa �� D Payment Data r <br /> Payment Type C _ Invoice# Check# � � Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />