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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 /> 1{3 <br /> `(✓L 6,(o <br /> Q / CHECK If BILLING ADDRESS <br /> FACILITY NAME 'FVE70 MOJOF PIZZA <br /> (VfjI f <br /> SITE ADDRESS Wo S. ` S!1/'rAM/ ft) ) /� 't /�752'VG <br /> Street Number Dlrectlon �Vlllt/ 1,1S'trree�l IN�ameV l..wCi "/ZI✓Co�tl'a� <br /> HOME or MAILING ADDRESS (If Different from Site Address) I v'y L+'1 `LILA 15e I I <br /> Street Number Street <br /> CITY ,._ ,1 J� STATE/Y /4 ZIP <br /> L� l !N I <br /> PHONE#1 -`- EXT. t APN# LAND USE APPLICATION# <br /> (?P4 ) 2147 - Lit 0(� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR j� I�1 �'l ^n <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# — EXT. <br /> lit r— �(D \AAC�ILrE- A J'Ji�I1J Zoo ZL12-4/o( <br /> HOME or MAILING ADDRESS FAx# <br /> v 7 PIA 0LS'/,L PLA ( ) <br /> CITY �(L.(ol�j STATE ZIP g5-Z 0 <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 HEAUFFI 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, S ATE and FEDERAL laws. //\\ <br /> APPLICANT'S SIGNATURE) -— — ��— — DATE: S/I I /Z-C)PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER / { OTIIERAOTIIORIZEDAGENT❑ <br /> If APPLICAA7 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 HEALTIt 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: 6 { `Q, W2 ( c`/-V <br /> COMMENTS: <br /> 4UGD <br /> SAN✓ ' ?ata <br /> ACCEPTED BY: W, 0 EMPLOYEE M DATE: <br /> ASSIGNEDTO: VQ EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVILE CODE: P i E:00 <br /> Fee Amount: • Amount Pai �5-a.v� Payment Date gI/ Z� <br /> Payment Type f Invoice# Check# 1124Z67 8 S— Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />