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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CCrS P -Ctt?b`I �/� UD(�3"75 71�ON41 5 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> ��9 Kf}(� �rizvl�L7�'► �n � <br /> FACILITY NAME C /lVTIJ Ko v) /3 <br /> SITE ADDRESS-7-70 v lu d rte[CL.«d ft• S C 4-101-7 <br /> Slmet Number Direction Street Name Cil 21 Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 'ghlr t I <br /> T0(-krl"l0 t V Street Number Street Name <br /> CITY �I STATE Zf <br /> PHONE#i Ext, APN# LAND USE APPLICATION# <br /> ('�2 ) —LM <br /> PHONE#2 EV. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -4tz DTmo <br /> ��""�T G CHECK if BILLING ADDRESS <br /> BUSINESS NAMEV-�4/ I` /1 kS D PHONE# I EXT <br /> HOME or LINGADDR SS (/j FAX# <br /> y w t7/ V n, l ! <br /> CITY �. STATE LP l ('C(qt / <br /> BILLING ACKNOWLEDGEMENT: I, 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 <br /> applic tion d that th ork be performed will be done in accords cc wt all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S a DERAillaws. % <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ERTQRUGER OTHER AUTHORIZED AGENT❑ S I C t�✓t. <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: t r <br /> COMMENTS; Vr <br /> 0720'A <br /> N eNtI /NCOU <br /> ACCEPTED BY: /�I r EMPLOYEE M DATE: rM� <br /> ASSIGNED TO: VS EMPLOYEE#: n DATE: /L <br /> Date Service Completed (if already Completed): SERVICE CODE: / \ I P/E. V <br /> Fee Amount. /0 Amount Paid '�22 Payment Date <br /> Payment Type Invoice# 6h Gf I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> � �6 �te2.33S <br />