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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FEST A-k IZAt4 7— I 0 S(Q. <br /> OWNER/OP RATOR <br /> g—/ C CHECK i1 BILLING ADDRESS <br /> FAGLITY NAME ^X( ( � �/ <br /> SITE ADDRESS ' r�( / w0 I '95 Z,lA <br /> 0'1 c/l Street Number I Direction Y / �'r `SReet Name t r � CI Zl Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVeet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I cam. APN# LAND USE APPLICATION It <br /> (Zoq) �d( - Zq8I ay a 0503(p <br /> PHONE#2 ExT• SOS DISTRICT �LI L0CATI�1(I�ODE <br /> ( ) UL <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 <br /> vvv <br /> ,y,1�, „' CHECK if BILLING ADDRESS <br /> BUSINESS NAME vvv VVV VVV-�.i--- i PHONE# n J E&Ae <br /> HOME Or'MAILING ADDRESS FAX# ,` V <br /> ( ) / <br /> CITY STATE �HN 0l1�1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or ��E^ �e, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges asSOcia roJ60t <br /> or activity will be billed to me or my business as identified on this form. NT <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,S FEDERAL laws. �y <br /> APPLICANT'S SIGNATURE: DATE: Z 2 Z <br /> PROPERTY/BUSINESS OWNERS PERATOR/MANAGER AUTHORIZED AGENT❑ <br /> If APPL/GwTisnotthe Bj,udNGPan7Y 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 JOAQOIN 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 /> TYPE OF SERVICE REQUESTED: S e-Q06 <br /> -5 7— Ael �'S/Q/�I r4 W67 As Al <br /> COMMENTS: / , " 12 (/tJ a"" C#4L rl-0 C./ .- <br /> rL-167 oXf , zc{-t� t�Fkav1 -51. 10 l{1>� <br /> ACCEPTED BY: ,fav-1,G.S2L� EMPLOYEE#: DATE: �rf 2�'�( <br /> ASSIGNED TO: yV1.WX EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 523 P/E: d <br /> Fee Amount: ,�� — Amount Paid/? L7�r 60 Payment Date <br /> Payment Type ( Invoice# Check# 1 ,3 2G�� Receiiid By: <br /> EHD48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 m 4 <br />