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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tvpe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (ACTVAlkt- <br /> I- <br /> OWNER/OPERATO <br /> 1D� CHECK If BILLING ADDRESS❑ <br /> Yl.l-� <br /> F cam NAM <br /> I t " LLC <br /> SITE ADDRESS C1 CJ y <br /> at Number Dlreetlon �/� Street Name �7J V(Clt� ZI —Codex <br /> HOME or MAILING ADDRESS (If Different from Site Address) 111V <br /> Street Number 1O��rP <br /> CITY ,r,/. e�— STATE M ZIP <br /> PHONE#1 EXC APN# LAND USE APPLICATION# <br /> 6071) 9b9- 1 <br /> PHONE92 EIT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C, ,^ I I _ moSes nit � ,q�/Ip <br /> JY I WVti LIST t t' l rL , I'C CHECK If BILLING ADDRESS <br /> BUSINESS NAME IS1'61n- FO` 'Duo L &l _�I; I Eu, <br /> HOME or MAILING ADDRESS l- IN` � PONE#FAX# <br /> 11(01 °5e✓v'`1 e kfe 2i I ( ) <br /> CITY ( wk C1"— STATE 6A ZIP 0 S33 <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 ENVIRONMENTA HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed tome or my business as identified on i to. <br /> I also certify that I have prepared this applicat n a4l1tha e w be rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T nd D I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPL/CANT is not the BILLING PARTY 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 ihYiymem"f is <br /> provided to me or my representative. DD��"" �r'rA+l m <br /> TYPE OF SERVICE REQUESTED: JC. YLI t <br /> COMMENTS: JUN <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ,.A1 , HEALTH DEPARTME T <br /> ACCEPTED BY: VV v EMPLOYEE#: DATE: <br /> ASSIGNED TO: U EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: nco <br /> PIE: <br /> Fee Amount 152 Amount Paid l 5 _ Payment Date LS 2- <br /> Payment <br /> Payment TypeInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />