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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE R�QUEST# <br /> Food SCVVI 1f rR 00 2-41 �6 1,9 WN6 <br /> OWNER I OPERATOR ` <br /> La <br /> Q. `y SCI t Z 1 <br /> FAC � CHEG/(If BILLING ADORE SSE] <br /> IfnY NAME ` rV <br /> Hct-riotHct-rioti Hen ChavclA+ehe <br /> SITE ADDRESS 10's 1n I I'�I L'y 7 <br /> Sueet Numaer Olmcuon �QIN Str el Nama I� t+Cl zi CC <br /> HOME or MAILING ADDRESS (If Different from Site Adorns) < AI I <br /> 5 Street N•mber `-' •"a�56�t am <br /> CITYSTATE ZIP <br /> �� CA -�I53 <br /> PRONE#I Ear. APN# LAND USE APPLICATION# <br /> ()AA) Ecu 1150 <br /> PHONE112 Exv BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR n <br /> ��/ � rd CHECK If BILLING ADDRESS <br /> BUSINESS NAME Hann �L PHONE# En <br /> NeK Cha✓GI Lte11 c u . _ ASO <br /> HOME Or MAILING ADDRESS FAX# <br /> 335 5 ndcwle ad I ) <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, Operator or authorized agent of same. <br /> acknowledge that all site and.for project specific ENVIRONMENIM HIaLLTII DI:PARTMI:NT hourly charges associated with this project <br /> or activity will be billed tome or my business as identified on this form. <br /> also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN Jo:Wt'I" <br /> COI-NTY Ordinance Codes,Standards,STA W and FE DL.HHHAl�la/wwsss.. <br /> APPLICANT'S SIGNATURE. rys ItpA..,/ DATE: II <br /> TIfit <br /> PROPER 'I BIN <br /> I SESS OANER❑ OPERATORI AGER "=OI1IERCA1T110�R1%EOAGE.%i (/,M'tQ•I'��ry�ti/�+"L.- <br /> /fAPPursl v isnot rile BILLAG A4RTt Praofof authorization to sign is required Tine <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, geotechnical data and'or environmentallsite assessment <br /> information to the SAN JOAoum CouNTY ENVIRONMENTAL.HiiALTll Dl:PARTmi:NT 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: <br /> COMMENTS: <br /> e4-1 " r✓_�Gj /I-' <br /> ACCEPTED BY: �— 2 n 11,11"7112 <br /> EMPLOYEE M % g D DATE <br /> ASSIGNED T0: �r EMPLOYEEM -��—� DATEDate Service Competed (if already completed): SERVICE CODE: Di'r Fee Amount: Amount Paid I Payment Date <br /> Payment Type Invoice'# CCh�e2ck#Q Rec <br /> EHD 48-02-025 �'D rtr J (1 �7 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br /> PCA � � s <br />