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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tof Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7yYAM,0Y,C al f ) r6; 3 <br /> OWNER OPERATOR eft <br /> t t .}b-ey- Sm <br /> Tl i OU N CHECK If BILLING ADDRESS <br /> FACILITY NAME CVACLoi~r- a `f <br /> SITE ADDRESS gQ \/t / I O T <br /> i-h S+Q, 1 ��A C, 01 5 31 v <br /> stt....I Number DimtIon Stioat�flame CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE � ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 201 ) 4t6 5 apt )35 05 bol <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Card. ID ^ � �. <br /> a 1 ' wt. � CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT, <br /> ,�phT.Y. S I�� t�2r-� Grec.w�r (D lb9 `j32 <br /> HOME Or MAILING (FAX# ) <br /> CITY '-T-f•a L J C STATE CA, zip 0%S2)', r <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 fort. <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 JoAQutN <br /> COUNTY Ordinance Codes,Standards,S TE and FED laws. n^ ^ <br /> APPLICANT'S SIGNATURE: �iA f%L���iL - DATE. X I I A 0 a a <br /> PROPERTY/BUSINESS OWNER LJ_ OPERATOR/MANAGER ❑ OTt1ER AUTHORIZED AGENT 11 <br /> 1f APPLICANT is not the BILL/NGPARTP proof ofauthorization 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 environmentaUsite assessment <br /> inforination t0 the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Satyr time it is <br /> provided to me or my representative. AY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: B 0! <br /> y�tiyo��IN ?p?3 <br /> ACCEPTED BY: YY- EMPLOYEE#: DATE: <br /> ASSIGNED TO: LPL L S EMPLOYEE#: DATE: 2--A <br /> Date Service Completed (if already completed): SERVICE CODE: Q PIE: O Z <br /> Fee Amount: i 5 6O — Amount Paid Payment Date -21//23 <br /> Payment Type Invoice# Check# 24 f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> n <br /> REVISED 11/17/2003 1 A !� <br />