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SAN JOAQUIN COUNTY ENVIRONMFNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> Un% nL% 6 rd- �s 5120 5 <br /> OWNER/OPERATOR r , /�( Cl/ECK If BILLING ADDRESS 1:1 <br /> uky�j Jae- <br /> FACILITY NAME <br /> un'on 1-� oz- hL Mtnl M + <br /> SITEADDRESS 1831 4 mFC 1J y08erni 4e AvE 1�ame-Ca co—;3-4 <br /> Sheet Numl»r at Name C ZIP Cede <br /> HOME Or MAILING ADDRESS (II DRferentfrom Site Address) <br /> Iql C Slnel Number SlInNR Nrme <br /> CITY STATE ZIP <br /> C q r <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 4:61 CCi- "IUs <br /> PHONE#2 ETT. BOS DISTRICT LOCATIDN CODE <br /> j4 ) CIO - -1115 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR �J) J^ CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME ��� PHONE# 5 ETT. <br /> Mrnl <br /> HOME or MAILING ADDRESS FAX# <br /> 1 /—Y'1 I ( ) <br /> CITY mcanker ok <br /> STATE e^ ZIP CT <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 project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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: uL]� cwt r�clef �'-n LXc DATE: r+ &51 xazz <br /> PROPERTY/BUSINESS OM:NERS OPERATOR/MANAGER ❑ OTHER AuntORarn AGENT <br /> JjAPPLiciNT is not rhe DILL/KG 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 HEALTti DEPARTMENT as soon as it is available and at the sam us <br /> provided to me or my representative. °' r f PAy nr1yED�rr� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Niv <br /> SPH IOPD Nf<`E'N EN\ <br /> ENV\,R�EVpP <br /> ACCEPTED BY: r EMPLOYEE#: $� a DATE: <br /> ASSIGNED TO: \ EMPLOYEE#: 8 DATE: ZS <br /> Date Service COmpl ted (If already completed): SERVICE CODE: ( P1E:i O`L, <br /> Fee Amount: 'J Z Amount Paid G S L Payment Date <br /> Payment Type Invoice# Chee" a !` 5t� �— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> l <br /> Scanned with CamScanners <br />