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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/ OPERATOR <br /> i'�v N+1 --G��f 171,2�ti Q LLC cxEcx if SiLLING A�DF2E55❑ <br /> FACILITY NAME <br /> SITE ADDRESS I✓ LVl�-�t..I �.�--t�� �jTC�GIG� �SZI <br /> e5bSE Street Number Direc€iori Street Name -city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 'DoVt-)u4 S T?L\)t] <br /> 25 1 Su(T:17 I I(DStraet Number Street Name <br /> CITY STATE Zip <br /> 7-051-vti—LE <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 547 1060 - <br /> PHONE#2 Ex7. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> V C_7`T -5prAC -NECK if BILLING ADDRESS❑ <br /> BUSINESS NAME � CI 4 Oew,,- CA-t,r fhWtA 1,Gc� "zONE# EE,,7*. <br /> GGaIo <br /> HOME Or MAILING ADDRESS FAX# <br /> Z2 S—1 "Dov i?c.v t> v t — HO <br /> O t ) <br /> CITY ?4;l5e Ct LL F- STATE ZIP �5%0& I <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, STATE an FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANA OTHER AUTHORIZED AGENT 1 ?t � At�►,Jr <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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice#R Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />