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- w SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME J JL, S C - IL q{,N 6n-P�6 <br />FACILITY ID # <br />SERVICE REQUEST # <br />FAX# <br />( ) <br />f ,,I l50 <br />CITY ()L KT`: -4 S A ZIP J �G <br />ACCEPTED BY:GL.�'t/' •e S C C7 <br />sumog&ega <br />OWNER / OPERATOR <br />'.1. <br />ASSIGNED TO: CLV-r-'� <br />! CH K If BILLING ADDRESS <br />) �C` C C/ f <br />FACILITY NAME <br />J .� \ <br />T Q- t ( " <br />It I`4 <br />y <br />SITE ADDRESS <br />PI I E. I O <br />Fee Amount: Gil., O _. <br />tYnO <br />Amount Paid <br />Street Number <br />Direction <br />Street Name <br />Cit <br />ZI Cotle <br />HOME or MAILING/ADDRESS (If ifferent from Site Address) <br />C # I S ?� ',L <br />Received By: <br />CI 1 Urt <br />&mbar <br />Street Name <br />CITY <br />1vll`T=�N <br />CA zIP95 20 <br />P` �E ij1 E'T• <br />APN # <br />LAND USE APPLICATION # <br />) 3q6 66 -6 <br />PHO E#2 <br />( 76) <br />ET• <br />3�I. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME J JL, S C - IL q{,N 6n-P�6 <br />zr. <br />/ <br />HOME or MAILING ADDRESS <br />l/Z7c�N C <br />FAX# <br />( ) <br />f ,,I l50 <br />CITY ()L KT`: -4 S A ZIP J �G <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, STA nd FEDERAL laws <br />APPLICANT'S SIGNATURE: +,Tr. � V Z <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTIHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PARTY proof of aathoriZaSan t0 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT as soon as it IS available and at thetl�tl'fejtilli� IN"le <br />provided to me or my representative. r/1i ryfC�1j 1 <br />TYPE OF SERVICE REQUESTED: TbOA pta-► c <br />NOVCOMMENTS: O [ D LO <br />SAN JOAQUIN COU <br />ENVIRONMENT <br />HEALTH DEPARTM <br />ACCEPTED BY:GL.�'t/' •e S C C7 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: CLV-r-'� <br />EMPLOYEE M <br />DATE:Z�— <br />Date Service Completed (if already completed): <br />SERVICE CODE: 5 ^I <br />PI I E. I O <br />Fee Amount: Gil., O _. <br />tYnO <br />Amount Paid <br />g— <br />Payment Date <br />Payment Type ori <br />Invoice # <br />C # I S ?� ',L <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />TY <br />NT <br />