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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ EST# <br /> _"r-uU 041 B <br /> OWNER/OPERATOR ` 1 <br /> t/Q�� O$e_ i1• Qr�—S �4Y-eiq CHECK If BILLING ADDRESS <br /> FACILI AME <br /> SITE ADDRESS <br /> k Z (\ Street Number DlreRlon Street Name �- CI ZI Code <br /> HOME Or MAILING{ADDRESS (If Differ(e�nt from Site Address) Z}w) ��o�kga L2 �r• <br /> �L`tO"1 ` Qne` 44 lie ✓ Street Number Street Name <br /> CITY STATE ZIP <br /> ti{oa(pS C 4 '15 5S3 <br /> PHONE#1 EM• APN# LAND USE APPLICATION# <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> / SERVICE REQUESTOR <br /> REQUESTOR <br /> JKIti OS t= �..�i�Q.-QS QVGq CHECK if BILLINGADORESS <br /> BUSINESS NAME A Vuq fir— PHONE# �' <br /> tF -2.XtCct✓. l—o� 415-) -1690-4 <br /> HOME or MAILING ADDRESSe} FAX# <br /> coq VHct V C\4 le 'Jr ( 1 <br /> CITY "" , 510 STATE ZIP p` S <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 a d tha a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and D L laws. <br /> APPLICANT'S SIGNATURE: DATE: a Cl l b 91 -Z,-t.I <br /> -----PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT is not the BILLING PARTY proaf ojauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 Ike same time it is <br /> provided to me or my representative. Ay <br /> TYPE OF SERVICE REQUESTED: CE <br /> COMMENTS: <br /> JOAOUI ?021 <br /> HEA( pEPM �ry <br /> f�(jbl co�swl hog► <br /> ACCEPTED BY: 1 EMPLOYEE#: U DATE; <br /> ASSIGNEDTO: fi�l l l,� EMPLOYEE#: DATE: fy <br /> Date Service Completed (if already completed): SERVICE CODE: P it: V�� <br /> Fee Amount: U Amount P /sa•(�D Payment DateZ <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />