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JAN JOAQUIN "UN'1'Y ENVIRONMENTAL HEALTH I)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C�v��e><� LL��, 5� s�©u3gib2 <br /> OWNER/OPERATOR <br /> VC' t GLti LL PekNn {uv,.� �eryV(�ej '� CHECK If BILLING ADDRESS® <br /> FACILITY NAME t� i l <br /> SITE ADDRESS C Z' , <br /> 110 Street Number Direction <br /> Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 4V ruc�wk wa+ ct\-c(e <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> S�cl2tor, Cv4- re�ln <br /> PHONE#1 ETT. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> IA. �1L� � 1tQ CHECKIf BILLING ADDRE55E] <br /> BUSINESS NAME ` n` PHONE# E' . <br /> VCt PN ci��z Ye'�rv�e u.v�. S'e r.,,z�. ( Z. Ciq;,-X7 <br /> HOME Or MAILING ADDRESS11 FAX# <br /> lte4 Fk ltiJ T et'J, (Z�S ) 4YB -�7a T <br /> CITY tWC Cq Cil Zee STATE ZIP <br /> ?or. <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 DATE: 8//-144 <br /> PROPERTY/BUSINESS OR'NER❑ OPERATOR/MANAGER J`[ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY 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 /> infomtation 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: <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> AUG 10 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: HEA T�yWPA E <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already co/hP!,9(ed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />