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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C AR-b Lo CIL. 54V qq6 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> I4I-LLA 9iL CO , LCC • <br /> FACILITY NAME �V{'F L'L At Q LL <br /> A � <br /> SITE ADDRESS (Al A-rER L 0 0 TZ - S T 0 C tL r0 nd of S"Z OS- <br /> 4D O Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) i hd t> Q E 17-C'Irl S-T` <br /> 2 34 0 Street Number Street Name <br /> CITY t'�/� v p V�- .r STATE C ^ ZIP 9 S 6 C L <br /> PHONE#1 Ll +`l Err. APN# /j /� 1-5-0 O LAND USE APPLICATION# <br /> (S30) Q�(0 It 7 J <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> rVII <br /> REQUESTOR PA ( CQ A,E� (AlL ,. A L-r0 CHECK if BILLING ADDRESS LQJ <br /> PHONE# ExT' <br /> BUSINESS NAME <br /> l,tlAc,Ta►,( ErEC.I �.c.EE2ru�. , �� C . 9r(o 31-3 — ltsL <br /> HOME or MAILING ADDRESS FAX# <br /> P. o , go X roams ( mp ) 3�; L- <br /> CITY W • C' P�-C T-Q STATE C+ A ZIP 47'-6 C <br /> l <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 t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA a FED laws. <br /> APPLICANT'S SIGNATURE: DATE: I t 3 0 O (o <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1M C 0&L7-r2 A-Cm z <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 dataftiid <br /> assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as tdftste time it is <br /> provided to me or my representative. <br /> 1 7006 <br /> TYPE OF SERVICE REQUESTED: L A,.,-( '(Z e V t E W c I n!T <br /> COMMENTS: DE� 20tgVIR�JNINIEN T HEALTH <br /> 0 PERMIT/SERVICES <br /> N00114 GpUN� <br /> SA ENS R M�MENT <br /> �EpLTH DEPA <br /> ACCEPTED BY: EMPLOYEE#: C DATE: /Z <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 !� P E: 30 <br /> Fee Amount: Amount Paid Z�S^D 0 1 Payment Date ( I b <br /> Payment Type Invoice# Check# 3 7 OS"7 I Received By% <br /> EHD 48-02-025 SR FORM _ o n Rod) <br /> i REVISED 11/17/2003 <br />