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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY IE # <br />REQUEST # <br />Anc"�, c iA 5�-tn P <br />FAX# <br />(� (SE�RVVIIC7E <br />V �`-'v � S'3-�;L'® <br />OWNER I OPERATOR <br />C V f- L:, up 5 / ` /l <br />CHECK If SICCING AdDRES <br />FACILITY NAME . p <br />IDSL\ L_1CICv �] <br />SITE ADDRESS IV6 -)}1,12 <br />L^r, <br />�� <br />LA r r�P,o� <br />�T S 35 C> <br />Street Number <br />Direction <br />Street Name <br />CI <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />it ( 7 L/ <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP Q 3 Sf Z <br />EXT. <br />PHONE #� <br />APN # <br />LAND USE APPLICATION # <br />�r72`�'�1�Z <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK 1f BILLING ADDRESS <br />1 7 C 1 <br />BUSINESS NAME <br />-DELI `Zfl—kCtu,. <br />PHONE # Q -7 EXT. <br />vl L <br />HOME or MAILING ADDRESS I9so cw' 110'aN2 CQ <br />FAX# <br />STATE n ZIP '3S30-7 <br />CITY �15 <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 or <br />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 ST TE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE:! Q! ZI, 1(-7 <br />PROPERTY / BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite asses ment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It is to me or <br />my representative. �7 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: JW11 <br />rV' ` <br />C <br />AN'to�QUI01? <br />H47H pE;RCD�rY�� <br />ACCEPTED BY: I� c vn �)e i--7 EMPLOYEE #: DATE: I lU r G((/ I j / <br />ASSIGNED TO: S I ' V EMPLOYEE #: DATE:I0 <br />Date Service Completed (if already completed): SERVICE CODE: 5 P/E: NO I <br />Fee Amount: q 5 Amount PaI Payment Date <br />Payment Type I Invoice # Check # I Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />