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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY 1D# SERVICE REQUEST# <br /> RE:5TA u KANT = <br /> OWNER OPERATOR <br /> GHuNNuPt -1U�t`t " �C�►l c-uA� CHECK if BILLING ADDRESS❑y <br /> FACILITY NAME <br /> KiMoNO S[J - •-r <br /> SITE ADDRESS _ .:. " � F <br /> 33 gG30 <br /> prCG f�Jp TRIQG � <br /> Street Number Dir Ion tree m Zip C9,Je <br /> HOME or MAILING ADDRESS (if Different from Site Address) P <br /> 1ZD <br /> 3313 �'ui.iftrt. <br /> 49 Street Number S"et Name <br /> CITY M0,PES-TD STATE ZIP <br /> r:�,A It 5 <br /> PHONE#1 ExT• <br /> (S l o} 3(p/�._ APN# LAND USE APPLICATION# <br /> q-1 I } � J <br /> PHONE#7 JT•. BOS DISTRICT LOCATION CODE <br /> ( 20q} 34o0- q 233 " <br /> 'CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING AD6kFssbJ <br /> [A/\. cs�l A G4 V) 11BUSINESS NAME PHO E# Exf. <br /> J <br /> HOME Or MAILING ADDRESSFAX# <br /> r <br /> 33 t3 LV 42 Alf!Z ( , <br /> CITY O n STATE I� ZIPqs3K C? <br /> S' <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 ENVIRON,1.IFNTAL HEALTH DEPARTMENT hourly charges.associated with this project <br /> or activity will be billed to me or my business as identified on-this forni. �! <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: DATE, <br /> PROPERTY/BUs1NFss OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLicRNT is not the BiLLiNG PARTY,proof of authorization to sign is required Title . <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,the owner or operator of the prop rty 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 ENv1RONMENTAL HEALTH DEPARTMENT as soon as it is available and at te time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Lj- <br /> COMMENTS: - ;� U <br /> S NJdgQUllV CQU <br /> 20t7 <br /> Com']G t7 q H�crN 1? pV E/V-r LAfry <br /> �. New <br /> ACCEPTED BY: EMPLOYEE#: BATE: <br /> ASSIGNED TO: !`J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ✓PIE; Q <br /> Fee Amount:. Amount Pa (]0 Payment Date <br /> i <br /> Payment Type Invoice# Check# ;! Rec Ived By: <br /> ,. EHD 48-02-025 ~ ` -+ SR FORM_ (Golden Rod) <br /> REVISED 11/17/2003 u <br />