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SAN JOAQUIN 6UNTY ENVIRONMENTAL HEALTH 6PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Gr W&S Cvrtd &.4-5 S kl� <br />FACILITY ID # <br />000, <br />BUSINESS NAME <br />V LtkG \V Cpn4rac4o' -] Aa- <br />SERVICE REQUEST # <br />OWNER/ OPERATQR-)� <br />J�, J <br />cL <br />HOME or MAILING ADDRESS <br />o�S35 (,J I waxVI r . <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />54 c k 4 -an 114-6 YvLAA CgLc W <br />c,6 11 <br />STATEp 14 ZIP Q x70 <br />SITE ADDRESS L, <br />-I <br />Street Number <br />E <br />Direction <br />14 t r►�a r L n <br />Street Name <br />ENT <br />sGk,�p� <br />40 Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />ASSIGNED TO: <br />Street Name <br />CITY <br />DATE: <br />STATE ZIP <br />PHONE #t EXT. <br />(any) g.s�, - Flo qo <br />APN #LAND <br />2 -ZZ0 -on <br />USE APPLICATION # <br />PHONE#2 EXT. <br />V' <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR c C t <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />V LtkG \V Cpn4rac4o' -] Aa- <br />/ <br />/ q➢/� / 1n0^•�- <br />PHONE# EXT. <br />(.-6� q( f- L 3 3 <br />HOME or MAILING ADDRESS <br />o�S35 (,J I waxVI r . <br />l <br />FAX# <br />(a09) 4-3 <br />CITYis 1 <br />STATEp 14 ZIP Q x70 <br />BILLING ACKNOWLEDGEMENT: 1, 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 or <br />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:,,S\>TATE and FEDERAL laws. Q� <br />APPLICANT'S SIGNATU (\\ �( DATE: <br />y/ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L�7 )�XIf l L 1 0U ► I Y7t` <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. 93 �-A _ <br />TYPE OF SERVICE REQUESTED: S <br />`�,�/ ` r <br />COMMENTS: <br />/ <br />/ q➢/� / 1n0^•�- <br />Sq/,/ N '.9'y ��? A <br />UOCI <br />l <br />Fj1j��gQU/ <br />FgCTy�� q� <br />� <br />ENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 4 <br />P / E: <br />Fee Amount: <br />V' <br />Amount Paid cti, <br />Payment Date 3 <br />Payment Type <br />,-_ <br />Invoice # <br />Check # 1 5 g , <br />Received By: <br />EHD 48-02-025 SR FORM ( of nCV <br />REVISED 11/17/2003 (J/, <br />