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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH*DtPARTMENT <br /> SERVICE REQUEST <br /> TypXgf Busine s or Property FACILITY ID# SERVICE REQUEST# <br /> 1\� S7au�c..r. New S(L 0b7'J�11 �I <br /> OWNER/OPERATOR r.�7 <br /> ice'' CHECK If BILLING ADORESSE] <br /> FACILITY NAME 1^ / <br /> SITE ADDRESS /V� ( F\Ci ACJLyn\i vI\ INN# 1 5 331 <br /> IT ICE,Number Olrec[ion � `I `I ��Name��� ��� ��� �+�Zi Coda <br /> orMaOGi,Qanc,pf er Ipm Site Address) <br /> �r 31 -7 - `bvs;nes5 { 'bf- <br /> -'1Y( T StreTet Number Street Name <br /> CIT emG cI-(. 0. STATE LL�J ZIP(?+t15174 <br /> APN <br /> PHONE#i e ExT' # LAND USE APPLICATION# /l 77 <br /> PH[[�h0N�NEE`+#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i Q <br /> n CHECK If BILLING ADDRESS <br /> .{� 1 1 / PHONE# Ex,. <br /> BUSINESS NAME!�P.'S/Q1A�Gl1 QSJ hC{(OUP C•` S � '3/G l7rJ6 �b <br /> Ho MAILING A DUEStteli FAX# <br /> CITY Los r el STATE ZIP �6 <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 /> 1 also certify that 1 have pre t iirefil s app lion and that e-w68tZD4i erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Co Standards,STATE an FEDE <br /> APPLICANT'S SIGN DATEDyy(�—, /.I ''1 Z�0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> /(APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 the same time It Is <br /> provided to me or my representative. <br /> "AYM <br /> TYPE OF SERVICE REQUESTED: T va', CSC ENT <br /> COMMENTS: _ y <br /> e j )cin ��2Gk ( Fac.osSfvIce p )ans} IDEC212015 <br /> NEALHOE'!r!EAT,LL T l' <br /> TMFA7 <br /> ACCEPTED BY:11 <br /> EMPLOYEE#: DATE: 12-- 2-1- 1-) <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: Cj1� P/E: I(1U) <br /> Fee Amount: Amount Paid <br /> Payment Type SGL Invoice# Check# Received By: //6. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />