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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b 594� <br /> OWNER/OPERATOR <br /> CotK1!���� CHECK If BILLING ADDRESS <br /> L.� t <br /> FACILITY NAME P���•s A`r I <br /> SITE ADDRESS <br /> �(.• W ' -c-st'L.It Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADD ESS (If Different from Site Address) <br /> SStreet Number Street Name <br /> CITY I STATE V— ZIP <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> (Loct,) X12-1(Yis <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME r PHQNe� �12 ! lux--+ E%T. <br /> HOME or MAILING ADDRES FAx# <br /> CITY I o STATE C LP <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 pd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE FEDERAL laws. <br /> PLICANT'S SIGNATURE: L cc DATE: I Z/f/Zl <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/A16AGER. ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING 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 andthe same time it is <br /> provided to me or my representative. IQY <br /> TYPE OF SERVICE REQUESTED: CES <br /> COMMENTS: DEC �2 202/ <br /> E1CTjyp�''^RTM H� <br /> ACCEPTED BY: ✓7A C� EMPLOYEE#: / f0 DATE: <br /> ASSIGNED TO: -%f t J EMPLOYEE#: IK 1 [/g DATE: ry 7- 2/ <br /> Date Service Completed (if already completed):j SERVICE CODE: P PIE: / r lei <br /> Fee Amount: Amount Pa• oU Payment Date <br /> Payment Type oLi� Invoice# Check# Receiv By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED II/17/2003 nvp1)5q I <br /> 1Y ,J 1G <br />