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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID If <br />G>1 <br />SERVICE qEQUEST If <br />HOME or MAILING ADDRESS( <br />AX# <br />os u e <br />og 7 Lif <br />WNERIOP RATOR <br />ftwy1FAL7if�gA17 <br />'QNT <br />CHECK If BILLING ADDRESS <br />1 \ •}�Y1` Gf\ <br />FACILITY NAME r ) <br />L \� <br />"0T <br />ACCEPTED BY: LAC <br />l 1 lJ <br />CC <br />SITE ADDRESS .230 V. <br />}�` 1 <br />C"1 I 1 G✓✓�\ CCA (�j'r <br />ASSIGNED TO: M((i <br />/'(iralready <br />1 <br />�'�'iJC 1'Y1vr <br />n <br />5,CU3 <br />34eat Number Direction <br />Street Nama <br />CI <br />ZI Coda <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) 130,1 <br />_ <br />/n�` I I <br />AV e <br />1 I r ` <br />9ZA_ <br />Street Number <br />2 <br />Street Name <br />C <br />Check # <br />STATE ZIP <br />Lh r <br />�P ON <br />aT <br />t <br />3s3- S 96 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR I <br />vO � CHECK If BILLING ADORESSO <br />I l/lr UY l <br />BUSINESS NAME <br />P NE rT <br />G>1 <br />— <br />HOME or MAILING ADDRESS( <br />AX# <br />os u e <br />CI CA STATE CAZIP ` <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 th work performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an -ED • I <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNE OPERAT / ANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />IfAPPt AAT is not the BILL G PARTY proof of authorization to sign is required Title <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 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, PAV1s__ <br />TYPE OF SERVICE REQUESTED: <br />walzra <br />jeC <br />COMMENTS: <br />QFC ?? <br />JOA ?�'i <br />ftwy1FAL7if�gA17 <br />'QNT <br />"0T <br />ACCEPTED BY: LAC <br />l 1 lJ <br />EMPLOYEE #: <br />DATE: I 12 'J I <br />I(1 <br />ASSIGNED TO: M((i <br />/'(iralready <br />EMPLOYEE #: <br />DATE: 1 <br />I9_9424 <br />Date Service Completed completed): <br />SERVICE CODE: ZZ3 <br />I PIE: <br />llobf <br />Fee Amount: '� • U <br />Amount Paid <br />9ZA_ <br />Payment Date <br />2 <br />Payment Type j•1, <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />�90�1�3c) <br />SR FORM (Golden Rod) <br />