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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �SERVICE RE rUEST# <br /> � <br /> 6 , t b 17L6(i �] <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS CJ <br /> URNciT 1 NL �7 n <br /> FACILITY NAME SAVE 19)V (A� LIQUOR <br /> SITE ADDRESS ZO 10W yo SLr+M/ ITE 111E <br /> I'( ci Zi Code <br /> Street Number DirectionStreet Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T APN# LAND USE APPLICATION# <br /> (M) 2-6q 41-0 D <br /> PHONE#2 N EZT. BOS DISTRICT LOCATION CODE <br /> �y ) 2ro3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORy� )r, CHECK If BILLINGADDRESS <br /> VPµl T 1lx``II l' EzT. <br /> BUSINESS NAME PHONE X <br /> SAvE © N 6)AS d- U'gt,o 09 26 <br /> HOME Or MAILING ADDRESS FAX# <br /> G2 W fl F ( ) <br /> STATE zip 95334- <br /> CITY k AN FICA- CP- <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 FERAL aws. <br /> APPLICANT'S SIGNATURE: DATE: 326 I261 <br /> PROPERTY/BUSINESS OWNE OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY Proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pfOl((/Bd to me or <br /> my representative. 1w`r■'EN e <br /> TYPE OF SERVICE REQUESTED: r� p r. <br /> COMMENTS: �Q� `o t J <br /> SA EN'JIROMERZMEN7 <br /> HEALTH DEPA <br /> ACCEPTED Y: EMPLOYEE#: �� 9� DATE: 3 7fp <br /> ASSIGNED TO: - / y EMPLOYEE#: 2(�`fv DATE: �c <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 21306 <br /> Fee Amount: �1 6 " Amount Paid 03-75 D-D Payment Date 3 1/3 <br /> Payment Type Invoice# Check# ;4,f Received By: L� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />