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SAN JOAQ60 COUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SUB -SE R v1 CF- D06'a10 <br /> CIMMER I OPERATOR CHECK if BILLING ADDRESS <br /> FAcLrrY NAME C �ry <br /> 50A Irl - <br /> SrrE ADDREssM Y x-r .✓L S 15 O C }CTO g5�OS <br /> 28149 E rest NumberDirection %mel Name city Zip Code <br /> HOME or M,AILING ADDRESS (lf Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> r` <br /> PHONE#t ExT- APN# LAND USE APPLICATION# <br /> s9 6 --690 jozo <br /> PHONEY ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR QE:—rE:;?S O w v I I7 u Y 0)aA V L I C. N C CHECK if BILLING ADDRESS <br /> BUSINESS NAME R „ ' PHONE# Err.s, <br /> ill�, eta -9;;*P S23=, JS'S- <br /> HOME or MAILING ADDRESS4>d L FAX# <br /> CITY yI H w/� STATE �"'� ZIP q,O <br /> JI LING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> �I 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 /> I also certify that I have prepared this application and that the worts to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> ,:;aAPPLICANTS SIGNATURE: DATE. -4 --/-0 —1!1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O OTHER AUTHORIZED AGENT .® <br /> If AaaucAw is not the Bi uNG PARTY proof of authorization to sign is required Ti rt e <br /> AUTHORIZATION TO RELEASE INFORMATION. When applicable, 1, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V1!i� (/! <br /> OLs 6tv <br /> COLMENTS: RECEIVED <br /> -- APR 10 2014 <br /> SAN JOAQUIN COUt= <br /> ENVIROMEPfTAL <br /> HEALT"0EPMnr--Z3 uTi <br /> ACCEPTED BY: EMPLOYEE M 2 6', DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date ServiceCompi (if airead ompleted): SERVICE CODE: v31 PIE: 2,303 <br /> 'ee Amount: .41 %16 , clu Amount Paid ` Bfl Payment Date to <br /> Payment TypeInvoice# Check# I Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> n7/17A1R <br />