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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILIITnTY IID# SERVICE R,E(QUEST# <br /> IAL%xo'R- STO2Y- GVU�SW S I"I <br /> OWNER/OPERATOR <br /> n Nt>4 JL^W�� CHECK If BIWNG ADDRESS❑ <br /> FAaun ME rNAl <br /> nTAV l,s <br /> SITE ADDRESS 5 C.µFY-13= L.L�Ni_ �pl 952-k0 <br /> �` Slree[Number Direction Stmet me C e <br /> HOME or MAILING ADDRESS (N Different from Site Address) <br /> Strea[Number Sheat Name <br /> CITY STATE LP <br /> PHONE#1 E'. 1APN# LAND USE APPLICATION# <br /> ('ZuY 1 321-Db� <br /> PHONE#2 E= BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK N BILLING ADDRESS❑ <br /> AN'Trt k roti <br /> BUSINESS NAME PHONE Exr. <br /> S C p tNC 'AZA '3TFIC- VIAR rr 20cl321-0630 <br /> HOME Or MAILING ADDRESS FAX# <br /> }� S- C)}t tzoF-rte Lnlept, I 1 ) <br /> CrrY 1,-M s zlpgs- .qD <br /> BU,LING ACKNOWLEDGEMENT: L 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, STATEAfid FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l DATE: WZ5121 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHERAUTHom DAGENT P3 P(ZrFS1Ol=JdT <br /> IjAPPLlCANT is not the BltuyG PARTY proof of mthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION- When applicable, L 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 JOAQWN COUNTY EWMONN ENTAL HEALTH DEPARTMENT as soon as it is available and the same time it is <br /> provided to me or my representative. Pq A Y <br /> TYPE OF SERVICE REQUESTED: QW --S 'IF 0 CEIV <br /> COMMENTS: <br /> SAN�o� ° 12021 <br /> ENVIRO 11IN BOUNTY <br /> HEALTH DEARTMENT <br /> ACCEPTED BY: `/, EMPLOYEE#: 'LCA DATE: <br /> ASSIGNEDTO: r-Tt`x EMPLOYEEM / DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: �0I PIE: <br /> Fee Amount: -U Amount Paid /S�t �Ll Payment Date <br /> Payment Type Invoice# Check# J�a Rece"rve y: <br /> EHD 4M2-025 SR FORM(Golden Rod) t <br /> REVISED 11/17/2003 S <br />