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SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grocer 5�trCsk- s <br /> OWNER I OPERATOR <br /> TDn Fow - CHECK If BILLING ADogesslz <br /> FACILITY NAME Il./o &VV� �O r' (� I 1 1 <br /> SHE ADDRESS 1/. 16 M aYC{, fel S"t OG�t�oP1 9S�IO <br /> SVeet Number Diractl n Slraat N ma It ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#9 APN# LAND USE APPLICATION H <br /> (408�y, X61 -23 <br /> PHoNE#2 Fxr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES7ORn L C C CHECK H BILLING ADDR5a5� <br /> BUSINESS NAME PHONE# • <br /> L V SI n -� &/11 (°Its ) `J 2 L 6 <br /> HOME or MAKING ADDRESS ,3 n ,r 1 � (AR# ) <br /> CITY C _ N`L1tIS�� STATE /JA- ZIP G <br /> 727 <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 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: a494 DATE: l ZI <br /> PROPERTY/BUsIN'ESs OtVNERE3 PERATOR I NIANAGER 10 OTHER AUTHORIZED AGENT❑ <br /> IfAPPLfCA,VT is not the Bad.LVG 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQLRN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: (If&W Co l)�-r(f(,'�I]'i/ FC -N <br /> COMMENTS: O <br /> SAro QFC 62o, <br /> II yRA TN R011V <br /> MRro �Nry <br /> M <br /> ACCEPTED BY: EMPLOYEE#: S DATE: <br /> ASSIGNED TO: EMPLOYEE#: n DATE: '}. r <br /> Gate Service Completed (N already completed): SERnCECDOE: PIE: <br /> Fes Amount: `4 FAmount Pa Payment Date <br /> Payment Type I�; --,,,�.. Invoice# Check# Received By: <br /> END 48-02-025 SR FORM(Golden Rod). <br /> REVISED 71/97/2003 <br />