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• J <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 11 FACILITY ID# /}SERVIICE REQUEST# <br /> 1 o bveo 0014VW i PrvICQ "&f 60011/0jC7 SAOMI�-,T9 <br /> OWNER/OPERATOR <br /> I 'fp`,An m 6rou I ! /� �n ,s ,l._ �I� 1 CHECK If BILLING AODRE55 <br /> FACILITY NAME V bYa\3 1�1�%rr----6�� 1 illi l/ V- CG G`CLV//II, i.--' I _ <br /> SITE ADDRESS ���� lJ�. � el <br /> imetNumber I DImalon 1 Slt�reet Name City Zip CoEe <br /> HOME Of AILING ADD xA(if Different from Site Address) 2l l�v 0 <br /> iV1CLt�ltn —�`IIt� Street Number Street Name <br /> CITY11�5 STATE ZIP <br /> PHONE#1 S}Or-t ?1,10"L EXT' APN# 0 11�Sp l LAND USE APPLICATION LI <br /> ' `-� <br /> PHONE#2 04,Me•r C.LI( Exr. BOS DISTRICT LOCATION CODE <br /> (20(o 0971 <br /> CONTRACTOR/ S VICE R&QUEST .R <br /> REQUESTOR lxc V CG�r,_ i— <br /> V 1` CJ (y CHECK If BILLING ADDRESS <br /> BUSINESSNAME <br /> �vV(wte C 1 G PH NE# ExT. <br /> Court ftis5 <br /> HOME Or MAILING ADDRESSFAX# <br /> CITY 12 _ STATE //A ZIP a <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 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 /> 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, ST TE and FEDERAL laws. <br /> APPLICANT'SSIGNAT�jj�]RE• DATE: C1 lwlz I <br /> PROPERTY/BUSINESS ON'NEuT` OPE TOR/D a 'AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfARPL/CANT,s not the BILLING PARTE'proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, f, 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 enviAmental/site assessment <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon a5 it 15 availab ae�ltj�Same time it is <br /> provided to me or my representative. F "'rFc <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 841V <br /> hF CTN��14Nq/v Y <br /> Qn V LI J i TMFIT <br /> ACCEPTED B : /,t A�I ULI EMPLOYEE#: � DATE: LI 21 <br /> ASSIGNED TO: vv•r/•I EMPLOYEE#: DATE: 2 <br /> Date Service Completed (if already completed). SERVICE CODE: P I E: I Lo'o— <br /> Fee Amount. Amount Paid <br /> 6-2•vb Payment Date l <br /> Payment Type Invoice# Check# 132_03%:KR cel d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />