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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E}DTEL d / r <br /> OWNER/OPERATOR <br /> T r;:-(-LT <br /> O CHECK If BILLING ADDRESS <br /> A ` I , I I NL <br /> FACILITY NAME -3 0 EV -r R A V ISL 'P( <br /> SITE ADDRESS S . 1 J4 XCL L Ar fa 12' L A-tl+R 0{O 9 S 3 3 a <br /> 15-600 Street Numbs I Dire Ion Street Name cry Zia Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> A VA E-- Street Number 5 Name <br /> CITY STATE ZIP <br /> PHONE#I APN# r, LAND USE APPLICATION# <br /> ( ) 1 i VAt( <br /> PHONE#1T BOS DIST ICT LOCATION CODE <br /> 1111 <br /> CONTRACTOR <br /> OR/ SERVICE REQUESTOR <br /> REQUESTOR IAA I C M A-F, -L ' • I A L-r-0 g CHECK H BILLING ADDRESS® <br /> BUSINESS NAME Yrt Vl/ PHONE# ' <br /> W44rLT09 Ci/BC.IA[�iE2ti . f - 9r4 3� 3 lrTt <br /> HOME or MAILING ADDRESS <br /> FAJI# <br /> P. O . ROD)( tf <br /> CITY , . 1r STATE (7A ZIP 5�f/ q 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 this application a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and EDE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> a{ b l0 } <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IDI O&Li—fZ A-t•,0 rL- <br /> If APPLICANT is not the BILLING PAR TP proof of authorization 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 enviromnental/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 REouESTED: P L A+4 -I7EV l&W U r' - <br /> CDMMENTGi <br /> f� l/ 's ��GLrN rnyR 9 2001 �APR E007 <br /> SAt'trJOAOLI M14 ALTM 'R I'Ti51ERVICES� <br /> ACCEPTED BY: EMPLOYEE#tt DATE• <br /> ASSIGNED TO: EMPLOYEE#: I j5 ATE: <br /> T1 ft 7 <br /> Date Service Completed (if already completed): SERVICECODE: � P/E: <br /> Fee Amount. go' Amount Paid Ip !) ! L��_; Payment Date 1c,--7 <br /> Payment Type �.: Invoice# Check# Received By: , t <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />