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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR p 5 a-7 gg 9 <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> 00 1 IqMo— TS �35c� <br /> OWNER/OPERATOR Lv�n eh! & mn� 1 Tkc. <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 7Q�/� IM1rt p ,Sze / , � ,, //tO <br /> Cuk <br /> SITE ADDRESS 7840 ri/ vs+el.Y('I/L'�1?i�(, �I�� EC-1 <br /> Street Number Direction Street Name Ci Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) (,(rG etert.„AVL <br /> Street Number VVStreEt Name <br /> CITY da <br /> + data- <br /> � STATE <br /> � / LA ^ ZIP ,)5051 <br /> PHONE#1 VN 1. 0 • L KEn. APN# LAND U E APPLICATION III <br /> 415) 780-055+ <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> _ o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# E�' <br /> HOME or MAILING ADDRESS FAX# <br /> l ) <br /> CITY STATE ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �1A'qyti [q, DATE: 4113 /20Z1 <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT[3 <br /> If APPLICANT is not the B/LLING 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: <br /> COMMENTS: <br /> V D <br /> CJ�a� <br /> apR <br /> q Ov0n�rsh�P <br /> Ht�T� FN qtVTY <br /> ACCEPTED BY: EMPLOYEE DATE: ' <br /> ASSIGNEDTO: - EMPLOYEE /J, DATE: I 2� <br /> Date Service Completed (If already completed): SERVICE CODE:✓lX / PIE <br /> : <br /> Fee Amount: 00 Amount Pai /S 0 Payment Date -5- 2-) <br /> Payment Type Ck-- Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />