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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST /9/Z 0 ,5 g727`3 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> n r tno\ cA <br /> %it-,cArdEf CHECK If BILLING ADDRESS <br /> 0 <br /> FACILITY NAME CL �V QL,tU�G( GV LI U <br /> SITE ADDRESS O 5 C(f 11 Porn t 4 Ste--X0(\OL e--X0(\ SA) <br /> SUNumber Direction Street Name cityZI Cada <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S„ SQL(U r r-e t1 t U <br /> Street Number Street Name <br /> CITY Ludt STATE ZIP <br /> CAq5Z(4u <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (c1.) 5y I - 1`l3y <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �J ,_^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME �luod" � Ci U PHO`E# ,/ U h E <br /> v.G <br /> HOME Or MAILING ADDRESS Irl FAX# �r <br /> ( ) <br /> CITY STATE ZIP <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. <br /> APPLICANT'S SIGNATURE: OAR DATE: I n'I I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not the BiLLINGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the prope �lpcated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen t+I �,p��,�,/'r�U t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at riV erg lits <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: oI D Z 20 <br /> COMMENTS: HEALTH Vff NT,qIvry <br /> ART'HFNT <br /> ( 03 q lerro I 10 's-Ac Cann <br /> ACCEPTED BY: EMPLOYEE V DATE: U '2 y <br /> ASSIGNED TO: rl EMPLOYEE#: -33( /) DATE: lO 2/ <br /> Date Service Completed (if already completed): SERVICE CODE: Qvi P 1 E.I t/03 <br /> Fee Amount: Amount Pakip /�� U Payment Date g/2-17- <br /> Payment <br /> 7- <br /> Payment Type Vlrse-' Invoice# Check# r t��U Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />