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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�afio g3 <br /> OWNER/OPERATOR <br /> If. ' �Za CHECK If BILLING ADDRESS El <br /> FACILITY NAME s1^ 001 It <br /> SITE ADDRESS i�0 1/ I IJ (h LM q6 � <br /> Street Number Direction Street Nama Clt ZI Catla <br /> HOME or MAILING ADDRESS (If Diff rent from Site Address) <br /> Z'O r' I oo Street Number Street Name <br /> CITY STATE zip <br /> LUT)l 6A °I Szy�j <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> ( zoCi ) 1-/CU -55-/& <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> S!}an E <br /> BUSINESS NAME1_ t; L15- PH�e# 9`00 -35-16 ExT• <br /> HOME or MAILING ADDRESS FAx# <br /> s nnE ( ) <br /> CITY STATE ZIP <br /> 5 K+E <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 l 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 laws. <br /> ,APPLICANT'SSIGNATURE: DATE: 2 /I YJ /ZC <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BLLL7NGPARTY 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 environme al/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available if r4) a time it is <br /> provided to me or my representative. F r�Fcc <br /> TYPE OF SERVICE REQUESTED: /C CO <br /> COMMENTS: JO Z0�[ <br /> � <br /> H ENSYU/N <br /> E4GTy�F,gbtF�N��Y <br /> GW WVt'T 1 q <br /> ACCEPTED BY: I I ✓� EMPLOYEE M 3U DATE: Z ' 2` <br /> ASSIGNEDTO: VAI 5V �nw EMPLOYEE#: fog DATE: 2 I % 22 <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P/E: Jw 3 <br /> Fee Amount: rij2 'G0 Amount Paid IGa — Payment Date ZZ <br /> Payment Type Invoice# Check# Received By: U�C1� <br /> EHD 48-02-025 � r`{"I I-7 G�I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V 7"1 ! J✓'-` <br />