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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE R/EEQQU'EES�T# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> E VA rN L/.1-Gt�H.T <br /> FACILITY NAME LI (9viziatJ <br /> SITE ADDRESS <br /> �05-5— EM ArN t-rcc�er 57ati�r/ <br /> Street Number Irectl0 S e CI Z Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Z-9-5-1 Doli I,t.q$ (3 LV p S tn.tTE I*11 O <br /> Street INumb <br /> CITYSTATE ZIP <br /> / <br /> 2OS&V 1 LLC,; <br /> LC &A 9 5 (O(p <br /> PHONE#1 Em APN# LAND USE APPLICATION# A Y/1 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE �D <br /> ( ) D T020 <br /> CONTRACTOR/SERVICE REQUESTOR SAN <br /> REQUESTOR rNVIRO- TUNTy <br /> CAW-6 V I1N 0 EF-VECW CHECK if Ell ti,,AL <br /> �t ENT <br /> BUSINESS NAME Na�.TFf5TAi2 E�Uv�/vEE�-/NG PHONE# EXT. <br /> 5--Z ( _ ;s Zs <br /> HOME or MAILING ADDRESS FAX# <br /> (,Ip /244— e,,7rLE61- <br /> ( ) <br /> CITY MoaC-STb STATE 04 ZIP gr3sY <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: �^-- DATE: /Z/31 /7-0 w <br /> PROPERTY/BusiNESSOwNGR❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EA/b/IV EER. <br /> If APPLICANT is not theBILLING PAR TY.proof ofauthorization 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: D r <br /> ACCEPTED BY: G� EMPLOYEE#: DATE:(� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed .(ifalreadycompleted): SERVICE CODE: i/-)/ PIE: C <br /> Fee Amount: ��� Amount Paid 30OZ) Payment Date 123/ <br /> Payment Type✓ Invoice# Check# I g 1 d Receiv4d By: . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />