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CAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LS�UO70? *.- <br /> OWNER/OPERATOR <br /> Z,-vs S CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS c cPcc �1Qly �c�1c:c,J F <br /> �jj S <br /> 2-ti � Street Number Direction Street Name Cit Zip Code <br /> HOME or((MAILINI3 ADDRESS <br /> ^(if Different from Site Address) <br /> �q Street Number Street Name <br /> CITY /1 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ► 132- 6�0 -- ��l f? - i - .ter <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE-7 <br /> ( ► 0 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR S CHECK if BILLING ADDRESS E] <br /> ��Li � �SJ'=t�"r�-5 <br /> PHONE# EXT. <br /> BUSINESS NAME / ESV VLSOV-4 2c- 36.7-3-101 <br /> HOME or MAILING ADDRESS 90L 1FAx# <br /> �nUC1y2- a tri w�l ( ) <br /> CITY Loy'1 STATE (f to ZIP 7 5 2146 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST rid FED 1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT S�rI�PP GJ4 c'a•/T X57 <br /> If APPLICANT is not the BILLING PAR TY,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 /> TYPE OF SERVICE REQUESTED: L r,� ,,Nat <br /> COMMENTS: 55 /19Z //I,-- ��� '1 OCT ��� <br /> � L•� <br /> moi/�� 1Zrgo27�� 3a sqN oC 2014 <br /> z�sr(fe;�!c !Y/ $;tli� I I I(,I Ili HFgL�H p qL TAL/y7y <br /> ))) ( RT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> tole (� <br /> ASSIGNED TO: 1, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 P I E: Z6 Z <br /> Fee Amount: &_` !}� Amount Pai � DD Payment Date (� g <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />