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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'PP.O5 L-1 SO 2-1 <br />SERVICE REQUEST <br />Type of Business or Property <br />Co-CCee S-kwe <br />FACILITY ID # SERVICE REQUEST # <br />3) 0 0 S 5'12_5 <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />FACILITY Kw <br />Yo•-c....te‘ ASI-eaCk C-c--ck-e <br />32-1 0 • Street Number Direction <br />'?,-..ckc-Ac_ isl-v-t_ <br />, <br />Street Name <br />s--,s_i,ct4t,,,,N <br />City <br />ci-VteLF <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />It.0 6 S.,sv-iye ,,, <br /> <br />L. Street Number V-k YCli1/4%. 1--1'\ . Street Name <br />CITY__ STATE ZIP <br />y\-Qc-tc <br />PHONE #1 EXT. <br />v-korrri i - 2-f.61- <br />APN # <br />k2s--02..c.- -c 3 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />(eerfr <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR' <br />1•Anv-V.._ Yyr-1--c,,,-\ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />F1 0\3,-k U-1--C- i)V.% Cv-wv,Ask--,sc-tc- CAiece- <br />PHONE # <br />(y-us, ) ii 1 - 2 “4 <br />EXT. <br />/ <br />HOME or MAILING ADDRESS <br />I faC,16 .SS 1(4 ra.)t LAA <br />FAX # <br />( ) <br />CITY (-1 STATE e4„\ ZIP Ctiz ej 1 <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: DATE: <br /> <br />PROPERTY PROPERTY / BUSINESS OWNER" OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 <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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: F-11)01( 7 (& IA Diki di_ <br />COMMENTS: <br />Y:ENT 0 <br />RECEIV20E2 2D <br />: 2 <br />SAN JOAQUIN COUNTY <br />ENVIR ONMENTAL HEALTH DEPARTMENT <br />ACCEPTED BY: 1M EMPLOYEE #: DATE: t 0 \-7_0 17, a. <br />ASSIGNED TO: k., EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5 s P/ E: 02 w 1 <br />242 2, Fee Amount: *4 (c, Amount Paid 4(.74 g <br />Pay ment <br />2-- Payment Date /,,b/yv <br />Type VI, k Invoice # Cperek # / 5-1 (i t v3 --7___ Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003