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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of 'Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACiLn NAME 60066E <br />Ron t ` V &T a6mm` Aima <br />i <br />SITE ADDRESS i`1—I <br />t <br />E. (6 <br />R -i t5266 <br />Street Number <br />Direction <br />Street Name <br />Ci Zip Code <br />HOME Of MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name- <br />CITY <br />STATE <br />(6126) <br />ZIP <br />PHONE #1 <br />EXT.' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT <br />BOS DISTRICT <br />LOCAi10N CODE <br />CONTRACTOR r SERVICE`REUESTOR. <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME o _ PH E Ems' <br />TEMCL z <br />E` r,MAILI%d1717 <br />S • ( '. s ' , I; ',`'.� I� i� ��t� I (�x� , ;-: ?: xF 4 „�" I' 't�� I <br />i i S Y <br />�� 1 , F <br />si k H y �) Rs a 4 '� l 4 <br />�iI aiy q �r R d �i <br />(� I L G ACIs1�T I)_GEME , I;wthe unde ign , 1: r ery, uslnes owner e t err rz x <br />:�� p 'e 7 <br />7Et <br />aC <br />owl edge that al� �i a ancl%6r prgi e t spe�Ific ENv ONMi NTAL 1IEALT EPAI� ` EI�tT ht I�rly ehal z; a o EIe wi <br />aet iwill be billed t me of my buiness as Identi#ied"""on this form <br />WN <br />I also certify that I have prepared this application and that the Work to be I erfomd will bje dont mco>e with'll� Sif <br />tAt <br />a� <br />COUNTIY Ordinance! Codes, ,standards, STATE and FEDERAL laws. ; <br />Al'PLtGANT S SIGNATURE ; DATE. <br />PR PE TY / BUSINES OWNER OPERATOR MANAGER ❑.' OTH AUTHO =D AGENT <br />IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Titl' <br />AU £II©Ri7.ATION T() RELEASE INFORMATION: When applicable, I, the owner `or operator of the, property located at the <br />above j'site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site' as�sessrnen <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tifne It is <br />provided to ine or my representative. <br />TYPE 00 SERVICE REQUESTED: eC p(JgCF, -jG9 ' W [0 P u t&�TA sena(-* - L Z .Plwl- IN <br />71 <br />COMMENTS: <br />OCT 2 4 2014 <br />iia' {- <br />ACCEPTED BY: EMPLOYEE #'iE. <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE - <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check Recelved By: <br />41 <br />EtD 4$-02-025��. 5� 0 Rod <br />REVISED 11/17/2003 � <br />i. , <br />