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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type ofBuslnessorPmperty FACILrnF1D# SERVICEREQIffST# <br /> OWNER It OPERATOR,Lk <br /> ,Z C. )) CeacK if El"wo AopREaa❑ <br /> FAMITYWAVE <br /> zL_c 41- `� Co 0 G <br /> SDEADDRESS 1250 <br /> IN C Z C <br /> HOMEor MAILING ADDRESS of Different from Site Address) <br /> Blurt Mann <br /> CITY STATE LP <br /> PNDRE111 APM R LAMD USE AppucAnoN R <br /> ISM Lt,k t <br /> ROME#2 Fn. BOS DISTRICT <br /> LocATKar ConE <br /> ( I <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> �"--�_��. r_ .'�A♦__�-'-T CdECKR BIWN6ADdtEd6� <br /> BusRESS NAME �n .� PRONE# En. <br /> HOME Dr MMUNG ADDRESS ' FAX# <br /> QTY STATE <br /> . may �'A: LP <br /> BILLING ACKNOWLUaaFrt'r: 1, We 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 we or my business as identified on this form. <br /> I also certify that I have prepared this application and dial the work to be performed will be dune in ocwrdance with all SA%T JOAQUIN <br /> COUNTY Ordinance Codes,Srartdards,STA laws. <br /> APPLICANT'S SIGNATURE. - _ DATeE . 7 <br /> PROPEIr Y/SUStNESSOWNEaO OPERA 01nEA Ae•THORISD AGENT <br /> 1fAPPLlGNT is not the B/l.LLNG PARTY proof of oArdtoH-Arlon to sign is repaired TiNe <br /> AUTHORIZATION TO RPUSASE INFORMATION:Whm applicable, I, the owner or operator of the property locatcd at the <br /> above site address, hereby authorize the rckase of any and all results, geotechnical data and/or environmmtalisite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at theain <br /> "pe it is <br /> provided to me or my representative. PAY�eOr Iv 1 <br /> TYPE of SERVICE ReQuESTEO: \"V: R <br /> COWENrs: <br /> p,UG � 4 Zoos <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPrm BY: EMPLOYEE#: DATE: <br /> Alis GNED TO_ EMPLOYEES: DATE: <br /> DateSerAceComDletad (BalreadyaanplaWS): StmrtcECaw. PNE: <br /> Z001- <br /> Fee Axnaumt: Amount Paid `d� I , Payme Date <br /> Payment Type f Invoice M Check# S2 Received By: (�T <br /> END48-02-02511 1 �� 7-0 �y „ �� 16.� � SR FORM(Golden Rod) <br /> REVISED 102712(X13 f1..�1 ,"'SY(' <br />