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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 196 <br /> OWNS OPERATOR r CHECK if BILLING ADDRESS <br /> Y-- r' v.ng �o•\�tA CGw\ an\� �hC <br /> FACILITY NAME (� \,�) <br /> SITE ADDRESS `� 'P \GC\�0� 2-� <br /> Street Number Direction Street Nar� Li Zi Lode <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) <br /> SAa•�.— Slreet Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#tAPN# ' /2 00 <br /> 1 LAND USE APPLICATION# <br /> (,LOA) 6yq— ZsS� ((f/ I/V <br /> PHONE#2 E'R' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 'BILLING ADORE. <br /> REQUESTOR •(J SC f �� X, Al. S HECK If SS <br /> BUSINESS NAME , \ I t,� -�•� (71 0 ^V UZ. <br /> I(OMEorMA1LINGADDRESS 1Q1 (� Fes# I�ZU <br /> CITY 'Aw\�, STATE ZIP <br /> �� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized qgeqi <br /> r <br /> _ acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associa <br /> activity will be billed to me or my business as identified on this form <br /> FM <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 /> _ <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t� .�,C ^t^i'� DATE: (d <br /> PROPERTYIBUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �LvT{c-r—�✓r•t�� <br /> If APPLICANT is not the BILLING PARTYY,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 PAY(`<�ENtime it is <br /> provided to me or my representative. <br /> r <br /> TYPE OF SERVICE REQUESTED: ;� S ✓ OCT <br /> NT <br /> COMMENTS: t!^ „ _ <br /> SAEWJOADUlN SONMEt�TTALTMSH <br /> l� lr ` f� �• 3„Cnt TN nFPARTMENT <br /> SU <br /> ACCEPTED BY: <br /> EMPLOYEE#: L DATE' 111 S a <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: I/-,O- --T— PIE: 23d� <br /> Date Service Compl ed (if already completed): _ <br /> Fee Amount: Amount Paid J (f L( � , L� Payment Date ;,0 v L�"1 <br /> -` Payment Type <br /> S Invoice# Check# Received By: , <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />