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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S&fi C701 <br /> OWNER/OPERATOR ' <br /> San Joa uih (Dww CHECK NBILlINO ADDRESS <br /> FACILITY NAME -T l,p(L <br /> SRE ADDRESS ��'0J) V �l G�ifo✓er rl�-OC k� X3710 <br /> Str«t NumEer Dbeclion fleet Neme I COM <br /> HOME or MAILING ADDRESS (If Differentfrom Site Address)P.O. BOX Z I?D0 <br /> Street Number <br /> CITY S STATE OR— <br /> ZIP <br /> PNONE#t Ext. APN0 LAND USE APPLICATION# <br /> (249g) yr08•q2 <br /> PHONE92 Ezl. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Shanhovi SOIl- <br /> an(] CHECK R&LLINOADDRESS® <br /> BUSINESS NAME Ah JDQ Ufr7 affit2 o( -f(a-hDV1 PHONE# Ezr. <br /> s a � � y6�- X79 <br /> HOME Or MAILING ADDRESS FAX 0 <br /> PO P?0X 21;D3O (;o9 , 14A -III-7q <br /> CITY S G FF V, STATE 61�— ZIP q q2 <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 /> 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 la S. <br /> APPLICANT'S SIGNATURE 4t�_ DATE: <br /> PROPERTY/BUSINESS OWNER13U OPERATOR/MANAk"MI ❑ OTHER AUTHORIZED AGENT I� jJ�ITfDv dN1lrl rr��l . <br /> IJAPPLICANT 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 t0 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 /> TYPE OF SERVICE REQUESTED: C WN5 <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L EMPLOYEE#: DATE: , 1 _ _ Z l <br /> Date Service Completed (N already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 2 Amount Paid Payment Date <br /> Payment Type Invoice III Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 n 9 o r 35 <br />