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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L ti `s <br /> OWNER/OPERATOR lie I <br /> { <br /> !I - CHECK 1}BILLING ADDRESS❑ <br /> FACIury NAME y-eiv <br /> SITE ADDRESS + I '1II�! ice)8 i1v <br /> Stmet Number DI don Street Now <br /> HOME or MAILING ADDRESS (If Different from Site Address) q r <br /> /�� T S Number tart Nam <br /> CITY I j� L% YO I� �✓ STAjE LP ` <br /> PHONE#1 t E.T. APN 0 LAND USE APPLICATION III (!/� <br /> 1 j6)6 S `-61 <br /> PNONE#Y EXT. SOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTORSERVICE RE UESTUR <br /> REQUESTOR © ,n/) i,R ,/� CHECK if BILLMG ADDRESS❑ <br /> BUSINESS NAME �`t°� l`YJ )f� fs- P Cl I G G' t 7 <br /> HOME or MAILING ADDRESS �+ �(/'� F�'�' <br /> 21 to Cir► ►�' e � � <br /> CITY / L <br /> 15-l"10 f o STATE/4 zip b 767 <br /> BILLING ACKNOtsWLEDGEMENT: I, the undersigned property or business owner,I'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:/ 1 Irk- SNoeL DATE:, 7JOfa <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEID AGENT r V••�'M"�'�� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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: L-� S /`✓Gy'✓4 L_ ~: -T 1 CN <br /> IQ K S �1 <br /> COMMENTS: <br /> JUL 12 2004 <br /> SAN JOAQLIIN COUNTYENViRONtt?ENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY; L EMPLOYEE#: ( 2-I DATE: 7 2-1 C', <br /> ASSIGNED TO: ,1 F EMPLOYEE#: F-T-) DATE: 'Z lt2--1& y <br /> Date Service Completed (if already completed): SERVICE CODE: /, t C/ P I E: 3 L� <br /> Fee Amount: 3 Z t = 3-7j-Amount Paid 9c-; Payment Date G' <br /> Payment Type Invoice# a Check# `` Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />