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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIl DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY IDNE REG A <br />E <br />,,I r� oo z 3 d s S' g_ <br />DINNER I OPERATOR cNEca irp x <br />W n <br />FAWnNAME 1 <br />SNE Actems ISoDV I I n �.SC ton Gs3Z�. <br />a .. <br />, <br />HOME or MAILING ADOAESs Or Dl(Nea nt Irem 611e Adams I , r , r- O I E-- <br />Crrr JCCLV) STArUe rn Z' G53 <br />�^. APNa tJela UeE AretaeATgNA 1 <br />c��a <br />PNAAE82 Pn. DOS DIarNn l�TlOa too[ <br />( 1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR 1U . ^ „w an ONEcaff it n <br />Busonaa NAME Y A <br />CUS �e I eVe. <br />HOME or IAuuMG ADDRESS FANA <br />1 1 <br />C" STATE ZIP <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 pmject <br />or activity will be billed to me or my business as identified on this forth. <br />1 also certify that 1 have prepared this application and that the we r to be performed will be done in accordance with ail SAN JOAQM <br />CouN Ordinance Codes, Standar , T O <br />: and FEDERAL Isw, <br />APPLICANTS SIGNATURE DATE: <br />PROr1KRW/RG5IX1a0i0w?"! Or.." II MANAGER I] OTTIPA AIInInRt?" AMW0 <br />1fAPPLJC AT Is not lite .Bl /- Nr� G PARTY, Proof Of authorization to Sign Is required Tbre <br />ALITHORI7ATION TO RELEASE INFORMATION: When applicable, 1, the owner or aperator of the propert he <br />above site address, hereby authorize the release of tiny And alp results, geotechnical date and/or iif_ &-A,� <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL Has HEALTH DEPARTMENT as soon it is available and at 163 /�n'1CAil, / <br />provided to me or my representative. O <br />%V <br />T <br />SR FORM (Gahan Rod) <br />EHO AS -02-025 <br />REVISED 11/17r7O0] <br />S <br />TYPE Of SERVKE REWESIED: <br />ClRamrta: SAN,/p <br />HegCTH FpMENTA <br />ARTME <br />ACCCPTED BY: ' Li � EMPLOYEE N: DME: <br />ASSIGNED TO: T � EMPLDYIF M: DATE: f <br />Date Service <br />P�S�II�s3 <br />Completed (H already complMad: <br />StaucE GaoE: <br />PIE r <br />Fn Amoun � Amount Pa J � Payment Dab <br />PaymenlTypa Involn N <br />Chuck N <br />R uhadr9y: <br />P�S�II�s3 <br />