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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP RATOR <br /> CHECK If BILLING ADDRESS <br /> J4264"lCa/v.Ss v Ca ass 0 <br /> FACILITY NAME q <br /> SuEAoDRESS <br /> 1.5751 <br /> Street Number Direction ��v �� treat Name city zip Code <br /> HOME Or MAILIIN�G AoDRESS (If Different from Site Address) <br /> 2 -1 jUG K ,,ogel Street Number Street Name <br /> CIN Gu/�- STATE G // ZIP ?563z- <br /> PHONE <br /> 15632 <br /> PHONE#1 EXT. APN#Oi)0-U Z 0 -03 LAND USE APPLICATION# 7 <br /> U- ) y-70 - X541 1 00 .- 060 - 03 c%(? � �I <br /> PHONE#2 EXT. 009- 70_rJj e,.10 .^06O.-/O BO8DISTRI T- LOCATION 90DE <br /> ( ) UD 9.-0 90 - e)-5 0-7 <br /> CONTRACTOR/ SERVICE REQUEST6R <br /> REQUESTOR <br /> /^ I k,-, CHECK If BILLING ADDRESS <br /> 39?BUSWESSNAMEyY ZLI rJ�QY�J\ S✓i �eJ {3 PHONEZ- Z� # �► 6 ) EXT. <br /> HOME or MAILING ADDRESS FAx#' <br /> (z.(Al ) 334- 2G> // <br /> CITY -Z-19 17, STATE 64 ZIP y5Z4 C) <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 DEPARTMEN"r 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 l 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/BUSINESS OWNER❑ ERATOR MANAGER❑ OTHER AUTHORIZEDAGENTZ I/f%sJQ� <br /> If APPLICANT iS not the BILLING PARTY.proof of authorizadon to sign is required 761e � t <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 /> 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: <br /> COMMENTS: V�A <br /> ACCEPTED BY. EMPLOYEE#: DATE: 1 - <br /> ASSIGNED TO: - hA/L EMPLOYEE#: DATE: <br /> Date Service Completed (i(already completed): SERVICE CODE: �c P I E:/, 'o" <br /> Fee Amount: 3� Amount Paid 13O �,� Payment Date <br /> Payment Type Invoice# Check# LA 4L IReceived By: <br /> EHD 48-02-025 PAYMENToRM(Golden Rod) <br /> REVISED 11/1712003 RECEIVED <br /> MAR 17 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />