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g' SAN JOAQUIN-,�OUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# pSERVICE REQUEST# <br /> 1' <br /> t-?6$-i CAaq -' L— Sir}`Q� 5 <br /> OWNER 1 OPERATOR <br /> C 00-VIA ©A %.Y 0, L L C- CHECK if BILLING ADDRESS O <br /> FACILITY NAME ,o <br /> SITE ADDRESaS ' ` <br /> J1 toLYmo►�'41 cxa�-ir c��v-r s�ur:u«yJ �szcl <br /> Street umber i CUDn Street Name CI Zi Cotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> +? QQTcLA(41r Street Number <br /> �nl 3y3 <br /> Street Name <br /> CITY STATE ZIP <br /> S-r0 LE-rTO,c) G%o <br /> PHONE#1 ExT. APN# 4(e a •—t LAND USE App,irATInu# <br /> (,?oq) 6o t—s 2 z <br /> PHONE#2 ExT. G BOS DISTRICT LOCATION COPE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C CNECKIf BILLINGADDRESS <br /> BUSINESS NAME /� l0` V l PHONE# ExT. <br /> ! L y'*t e�v fi 4% (90 C of <br /> HOME or MAILING ADDRESS FAX# <br /> 15)UA i L L yt D V. " f u"I r t4 Y (2 ) 1?r'7—g 1 <br /> CITY S 7-0 C-C-{Mt") STATE ZIP CFS-?C�7 <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 /> t or 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,STAT EDERAL laws. <br /> APPLICANT'S SIGNATURE: C<-4- DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ �U N_c�I` !h� {i ,(�tvn/t°(� <br /> 0 <br /> ]fAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Trtte <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 /> j 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: -C L jL-I-A C e SU&.SUL"tCi0 G e Oe ✓'f` �4)E'Jb L-(- <br /> COMMENTS: <br /> LCOMMENTS: � ��GG �" � ! � RECEtivED <br /> DECSAN r'OU <br /> RONMEkIT <br /> �}{DT PARS N ' <br /> ACCEPTED BY: D J C EMPLOYEE M Zf DATE: / 4 U <br /> ASSIGNED TO: SCD t`ro EMPLOYEE M t J -9 L_( DATE: [ (->-t 41� <br /> Date Service Completed (if already completed): SERVICE CODE: 3�� PIE: <br /> Fee Amount:. .2-3 p �� Amount Paid '$� Payment Date 1 0 ! <br /> i Payment Type Invoice# Check# -7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />