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SAN JoA*COUNTY ENVJRONmENTALHEALTa"EPART"ER ECEI`V'E <br /> SERVICE.REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> H 1�A ''`' 1 c) �. �I 15WO 16 201 <br /> OWNER/OPERATOR Ccs.ko-6 CHEF TAL <br /> �j BTU GO OTA CHIT <br /> FACILHY NAME COW <br /> SITE ADDRESS ko Vf E . l-Eb.mM r LCM0 <br /> Street Number Street Name ChyL e <br /> HomE Or MAIUNC ADDRESS (N Different from Site Address) 1 1q tQR-) <br /> 1� C,Oe,r�� t,, i 1 L`! Street Number t t '` Name (r-y <br /> CITY 'i_ V V tiy&U%Ckt 1... STATE �L A ZIP C16y" <br /> PHONE M Er' APN# LAND USE APPLICATION# <br /> PHONE#2 st,; BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> � T��rp�Ty� r�r� ^� ��+y CHECKif(31LLIN)G ADORE53 <br /> BUSINESS NAME' `i�`Lrt\`V�-'1-�k�C�1 l kT 14,FI, 0KD (V) Exr' <br /> HOME or MAILING ADDRESS 25y-, j�d (/..NAM O'- Fax# <br /> CITY STc)CX�`CUt'l I C� gSJ STATE ZIP l <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 ails application and that the work to be performed will be done in accordance with all SAN JOAQurN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: :.6 V DATE:�� Q_IS <br /> PROPERTY/BOsumsowNER❑ OPERATOR/MANAGER ❑ OTHERAVCHORIZEDAGENI' 'Q1FPPt �i'-,NTA-!1`1 , <br /> IfAPPLICANT is not the B7uaucPAN7Y.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 ENvIRDNmENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 1 1,,+ <br /> TYPE OF SERVICE REQUESTED: �''?� imlaot 1 nao ttoc 5otor to ' ¢QI�1 `�I�C.) r..,t_(.`�)C. <br /> COMMENTS: FN ? <br /> D <br /> Oat <br /> ACCEPTED BY: EMPLOYEEM DATE: I ( tF <br /> ASSIGNED TO: Z i EMPLOYEE#: DATE: 1. <br /> Date Service Completed Of aUpdycompleted): SE2VCECODE: 'Gi PIE: Z Q <br /> Fee Amount 0 Amount Pai 3 40, pb Payment Date 3/ <br /> Payment Type Invoice# Ch # �b/7 ReceBy: <br /> EHD 48-02-025 SR FORM(Guidon Rod) <br /> REVISED 11/17/2003 <br />