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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER!: OPERA/ MANAGER or OTHER AUTHORIZED AGENT 0 <br />2 3 DATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rib a c)\-1° <br />FACILITY ID # SERVICE REQUEST # <br />42 g,00 6 c---_, 7......, <br />OWNER/OPERATOR 1 01.„ Do <br />CHECK if BILLING ADDRESS <br />FACILITY NAME L.--- 't-klatil <br />SITE ADDRESS --I ks- <br />Street Number Direction <br />5 •-rKet C41' 0-eVA <br />- Street Name <br />1- a • <br />CTty <br />) 9 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />'7 5) 4 Vail livelCs C f PI, Street Number Street Name <br />CITY <br />Ale" Ote.5+0. <br />-111tTE ZIP <br />3S-3-5:4 <br />PHONE #1 EX I . <br />(Z5.) 3 1 4—C Li 6 7 <br />APN # LAND USE APPLICATION # <br />PHONE #2 .— Err. <br />( ) britaj : bc77 "1-iti AN 0 1 0 4 0 -i clhev - co711- <br />BOS DISTRICT e--) <br />.../ <br />LOCATIODE <br />C4 , <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />;diliP, 61 ut,4-ve______ CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />Crrv STATE ZIP <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 />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 t ime it is <br />provided to me or my representative. MPAII <br />TYPE OF SERVICE REQUESTED: .r , 0 d eiayi dit_i„t_ <br />Acczyv- v 41 <br />z <br />COMMENTS: <br />_AN 3 , <br />ssAlv ,-,,c, '2023 ,q <br />1.1 4viii.QuIN C <br />rl DE.P477-4/, ' r <br />4447. <br />ACCEPTED BY: <br />/ Vi' tioU2-- EMPLOYEE #: DATE: <br />ASSIGNED TO: deo4 e_ EMPLOYEE #: DATE: ... -22 1_ -zo T5 <br />Date Service Completed (if already completed): , SERVICE CODE: , -7 P / E: N (a, <br />Fee Amount: L.) A ., oo Amount Paid L.... --- 14<s;35 Payment Date 3i i 2 ,s <br />Payment Type 0/ 60_4 Invoice # .....Speckr: 1 cic04,-/.. yco Received By: EAA1275- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003