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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7sz1 Sk00 5?9 -7 <br /> OWNER/OPERATOR (T/�,p CHECK If BILLING ADDRESS <br /> S ►D€er .) Nri <br /> FACILITYNAME r,rT/I ^� /�,�u�' � S 1 kTlo" <br /> SITE ADDRESS III ( lYl '• C 1 LE M ��y (,N Ir O'+� I °!S� Z d <br /> Street Number DlreoNon K Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sfreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f Exr. APN# LAND USE APPLICATION# <br /> (2ff1 > 369 - 36 '13 o `Fq- ZSa-(PL9 <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR M <br /> Teryly- CJ~^ TC_ J�grf S// p# <br /> urC <br /> HECKIf BILLINGADDRESS <br /> ❑ <br /> BUSINESS NAME NE# EXT. <br /> ELITE L IUC 9-09 633 <br /> HOME Or MAILING ADDRESS <br /> 25 35 IOICILoA NA NZ 209) 1461 - 6 342- <br /> CITY <br /> 42CITY SrTO C K-Fn N STATE C, /t zip 015--LO <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 ap lication and that thew rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and EDE ZAL law <br /> APPLICANT'S SIGNATURE: ' DATE: <br /> PROPERTY/BUSINESS OWNERJI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANzisnottheB/LLimGPA2Tr proof of authorization to sign is required Tine <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 environmental/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 REQUESTED: PAYMEPI <br /> COMMENTS: OGI S ' rSl wll <br /> G '_ '— DEC - 1 2009 <br /> S 'ENVIRONMENTAL <br /> HEALTH{DEPARTMENT <br /> ACCEPTED BY: ©( ( UEr EMPLOYEEM 03 DATE: t2 (C <br /> ASSIGNED TO: q tO t'T- EMPLOYEE#: I rL7ZZ DATE: f f Q <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: Z3 01 <br /> Fee Amount: 3 LE.S; '0 Amount Paid s Payment Date 2 t l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />