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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ACzU1.70 KFS AE1V; 053- 14 -ay- -SP )&'S <br /> OWNER OPERATOR 1 �t CHECK If BILLING ADDRESS <br /> FACILITY NAME N/Al <br /> SITE ADDRESS ) 7 30 LD h5`S k c l MAt-1_ LA rIE �oti1 9.5240 <br /> Street Number Direction Street Name Ci Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> A SIT Street Number Street Name <br /> CrrrSFihE As Srnre ZIP <br /> PHONE#1EM APN# LAND USE APPLICATION# <br /> 73 -'5310 �,��1 , 6a3- 14 -o _ P Pr oa- a <br /> PHONE#2 Ex . BOIS DISTRICT 7, LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C U 1 1 S <br /> CHECK If BILLING ADDRESS <br /> I <br /> PHNE EXT. <br /> BUSINESS NAME CI\II L ENC;I N�tQ ("I' <br /> 3(� S_- 4S9 <br /> HOME or MAILING ADDRESSFAx# <br /> 419 MP,T�Hty-� PLt�Z.A ( <br /> CITY L(DD( STATE ZIPr9524-0 <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 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: `�Z& c DATE: 0 6/(5(/()Z <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT GIYIL j=K��IfJ �� <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 /> 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 /> TYPEOFSERVICEREQUESTED: "51)RfAC `rT JU`3jvQ P.�'� CrI`4'f1MWA-A1 Ct'l Rn--n2 / R. VIE`N <br /> COMMENTS: I ,Y PAYMENT <br /> RECEIVED <br /> God yiat�roo�► JUN 720 2 <br /> SAN JOAQUIN COUNTY <br /> 3 O PUBLIC HEALTH SERVIC S <br /> ENVIRONMENTAL HEALTH 510N <br /> APPROVED BY: EMPLOYEE#: L DATE: b-Z <br /> ASSIGNED TO: , } /O - EMPLOYEE#: O DATE: � /O'/6 <br /> Z <br /> Date Service Completed (if already completed): SERVICE CODE: t PIE:�(Pp <br /> Fee Amount: pp Amount Paid l r7 R _ Payment Date I1 OL <br /> Payment Type Invoice# Check# GJI 5 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />