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SAN JOAQUIIOUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S.sC 000 :ms2. 3 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> 5 3e- FL-1-£r S£"=£-S OW=:xVr.3 DP0.t (Y"CC*k)#j — ty►6Q. <br /> FACILITY NAME <br /> :s7e- Go"ov a-r� )P Aa-b <br /> SITE ADDRESS & I AAS his AV$Nu L STa�"� CA 4$� <br /> 113(D Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> Err. FAPN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'TLS€ 'aPCHECK if BILLING ADDRESS <br /> . TN ��'�-E� <br /> PHONE# Exr' <br /> BUSINESS NAM <br /> fjA&Lrsy mac. 3&7- 4-Poe) <br /> HOME Or MAILING ADDRESS GG=� <br /> C <br /> X370 5uxV- 4' (20q) '3&7-'54-241i <br /> CITY �O�y STATE ZIP qS Z 4.0 <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 <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 and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: � / Pr/ <br /> PROPERTY/BUSINESS OWNER[3 O TOR/MANAGER ❑ OTHER AUTHORIZED AGENT U:ST C4T �!T®� <br /> IfAPPLICANT 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: SM exc qA ry R tip^wa-- ®r- (•�itl�Ty V L'��ObQ �D J TL..S -34 RV �� <br /> &Uu,.IG S'fn446E lftvK mbo x"VA-zo-j4 JUN 2 9 M2 <br /> SAN JOAQUIN COUNT! <br /> ENVIRDEP�SENT <br /> ACCEPTED BY: L(u-,,:, EMPLOYEE#: qC)-S7� DATE: 42/2-", (12- <br /> ASSIGNED <br /> tZASSIGNED TO: I til 0 <br /> EMPLOYEE#: qL( f,� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ?�( <br /> Fee Amount: �� Amount Paid /— Payment Date <br /> Payment Type Invoice# Check# y� R eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �^ <br /> r � <br />