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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property -FACILITY ID I SERVICE REQUEST#_ <br /> OWNER/OPERATOR ^ — BBIu1NGA(/o�oaiEs✓S,❑ <br /> 61 Iioet- � . sG+r�o CHECK <br /> FACILITY NAME •, Yl <br /> SITE ADDRESS 'S/ E �-r "" -P i �'/�Y/�OP <br /> Street Number Directl n S Na C Zip Code <br /> HOME or MAILING ApDRESS in DNfererd from SM Address) <br /> 32 N- /rlAIW SI� SbeetNumber <br /> CITY /1 A STATE LPy <br /> PHONE#I P'�T APN# (�,f�" LAND USE APPLICATION# <br /> (.7,01 ) ! I /96 -o8r - 7/ <br /> PHONE#2 En, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> /_/Z-/J � -� q ,/`I/i�i ) 1 / CHECK N BILLIJNG ADDRES{Sp <br /> BUSINESS NAME J_�f "' C P N�( v 7 2V <br /> HOME or MAILING ADDRESSAr# <br /> CITY / `+' T fi'n �I STATE /f i] L15 �P 01 ., O <br /> BILLINGA KNOWLE _ NT: 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 <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 JoAQutN <br /> CoaNTY Ordinance Codes,Standards,ST an nmA[,laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not theBiLLwcPde7r.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 JoAQUtN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and WL a same time it is <br /> provided to me or my representative. q y <br /> TYPE OF SERVICE REQUESTED: , • Vr I <br /> COMMENTS: <br /> q{, <br /> LJ �3 <br /> Of pueXSrP Oz0 <br /> 2 <br /> OgQu/NH4CT�F �?NrY <br /> 844 <br /> lvr <br /> ACCEPTED BY: MIA0 <br /> EMPLOYEE#., CMD DATE: 13 <br /> ASSIGNED TO: Par l �, L- I <br /> EMPLOYEE#: Ge7 YJ I <br /> DATE: o <br /> Date Service Completed in already completed): SERVICECODE: ( PIE I V!y <br /> Fee Amount: 2 Q Amount Paid /j�, Payment Data <br /> Payment Type Invoice# Cheek# 3�2— Recely d By: <br /> EHD 4 �n A�r �eI SR FORM(Golden Rod) <br /> REVISEDED 1111 11/17/2003 <br />