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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> 17U FA 00 00 3 ?-z SR�O�'Co11 <br /> OWN�FZ/OPERATOR p <br /> �-`e, Grcuclf BlLura aooREa�❑ <br /> FACILITY NAME / <br /> SITE ADDRESS Z21-6 <br /> / c��/� Ave, <br /> e KCAL GsteeN r street N �I53�0 <br /> Z Coae <br /> HOME Ot MAILING ADDRESS (If Different from Site Address) <br /> CITY street Number Stand Nam <br /> STATE IIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (Look )812,-0030 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> C CI�CN if BILIJNG ADDRESS <br /> Ef <br /> kir <br /> BUSINESS NAME t PHONEIf E" <br /> DOWS C 1�, Z04 2-4030 <br /> HOME or MAILING ADDRESS FAx# <br /> Z24 I <br /> CITY CSCAL.ON STATE /'H ZIP „1S-y w <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 ENA IRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fomi. <br /> I also certify that I have prepared this application and drat the work to be performed will be done in accordance with all SAN JOAQmN <br /> Cut-'TY Ordinance Codes,Standards,STATE and FEDE2u.laws. <br /> APPLICANT'S SIGNATURE: �,� I DA Il 2812,E <br /> PHOPMTY/BUSr.NRSSOWNERI' OPFAATOR I MANAGER 01 11F AUTHORIZED AGENT❑ <br /> Ij.4ppLicAT is not the/JILL[,VG PARl i"PrOoJOfOnllrariZafiOtI fa sign iS required Tile <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, gcotahnical data and/or cur lrorrmenwUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL ITT 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: eX ` <br /> COMMENTS61 <br /> : <br /> ° 5343a �� y <br /> ACCEPTED BY: a EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: O DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE. u061 PIE: D Z <br /> Fee Amount: G Ariount Paid j ( (" Payment Date ? <br /> Payment Type Invoice# Check# ,I �� ij Received Eiy: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> REVISED 11/17(2003 <br /> f, <br />