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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Boa Trwr�L— SR0 0 858 ig <br /> OWNER/OPERATOR ,,(r�� / l <br /> U,w\6,\-Y- CHECK If BILLING ADDRESS <br /> FACILITY NAME �Q.SU� \'Y\O-yy\ o v\a C,,UU <br /> SITE ADDRESS '1620 Is � ,PCU <br /> Street Number Direction AY LC' Street Name , Cit ZI Cotla <br /> HOME Or MAIL(hNG ADDRESS (If Different from Site Address) C� q �� -L rI <br /> 16 7 / Street Number `J� T �SttreettNName <br /> CITY L•I ckl � STATE CA ZIP <br /> 59 0 <br /> PHONE#f "�T�1 Ems• APN# LAND USE APPLICATION# <br /> I* )5?o- 36Z 4 <br /> PHONE#2 En, BOS DISTRICT LOCATION CODE <br /> ( ) t-i 0 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME {'\ PHONE# Ear' <br /> Q S vA C w ob D <br /> HOME Or MAILING ADDRESS <br /> 16 <br /> ?? S-V�f ' O ` 4 rL � FAX <br /> l lJ t I�C/Y ( ) <br /> CITY �i, �,A_yro STATE 0i' I zip <br /> BILLING ACKNNO �\WLEDGEMENT: 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 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'S SIGNATURE: 5 DATE: f D/06/7 © Z Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART T proof of authorization to sign is required Titie <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 and at "is <br /> provided to me or my representative. RECEIV <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> EJOAQUIN COUNTY <br /> NVIRONMENTAL <br /> HEALTH DEPARTME T <br /> ACCEPTED BC EMPLOYEE#: DATE: CO/ ZrL- <br /> ASSIGNED TO: L- a'SX, h� EMPLOYEE#: DATE: (D I ZZ <br /> Date Service Co Impleted (if already completed): SERVICE CODE: 6`7J P 1 E: O 1 <br /> Fee Amount: p$ Amount Paid — Payment Date I 0 )j ]- <br /> Payment Type V / 5 Invoice# Check# Received By: <br /> EHD 48-02-025 2102c�J /S / b 3 r 2:) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 3( f <br /> 6 � - <br /> Cl <br />