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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C0Yy1 ° dUp-ou113 <br /> OWNER/OPERATOR <br /> l` ,Q - U S co e Z CHECK If BILLING ADDRESS <br /> FACILITY NAME t <br /> > �!� oros ` uil/o <br /> SITE ADDRESS -73 V 5 Co/t F'o�n is '5CC c n c�52o3 <br /> Street Number Dir—tion Street Name CI ZI Code <br /> NOME or MAILING ADDRESS (If Different from Site Address) <br /> 12,2- QU e r C Street Number Street Name <br /> CITY STATE ZIP <br /> 5 OCA ar CAViEocnlcn 2cy <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (2(-9) 15 - 1 i -� - �_ ' <br /> PHONE#2 EXT• <br /> 65- BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CkW <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �^kQ I� <br /> Ses S® Qr O S e snQnUl 2 CHECK if BILLING ADDRESS LO <br /> BUSINESS NAME PHONE# EXT. <br /> grQS UillI_ 09) <br /> 209) ' 15 - l <br /> HOME Or MAILING ADDRESS FAX# <br /> 132 /Ci G+Pr G¢ ( ) <br /> CITY 5 OC / ton STATE ' IP <br /> l` r Mornl�} 520S <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, STATE and FEDERAL laws. y� p� <br /> APPLICANT'S SIGNATURE: S�7f y�/r(� V 'q 'r� of DATE: 0 J /-26/20 Z/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLICAA'T IS not the BmLtKG PARTY Proof of authorization to sign is required rl tie <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 as soon as it is available and a¢fj�]e,ganie time it is <br /> provided to me or my representative. a /�/�YM <br /> 041 TYPE OF SERVICE REQUESTED: i <br /> COMMENTS: <br /> X76 Zp71 <br /> SANT <br /> E1V40 <br /> HLO U/N Co <br /> � R IV <br /> ACCEPTED BY: W Pt(� EMPLOYEE#: 77777-- <br /> DATE: <br /> ASSIGNED TO: 'S(L O K 2$C'(,l U Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: `V 6 1 PIE: <br /> Fee Amount: 1 'Z dO Amount Paid ►5 a Payment Date <br /> Payment Type CJ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> f'--o'sqZTI �r s <br />