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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Nana Bears W�n� ponuts o027� 3 �/� y <br /> OWNER/OPERATOR ^' —/t <br /> I n a /"��i}s a CHECK If BILLING ADDRESS <br /> FACILITY NAME La+lt rD To o d P I a <br /> SITE�ADDRESS T 446irlav) Road --a-�-�^ r0 x(5338 <br /> 1�W I Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (/` -'Tr <br /> (0t$0 Town S Street Number `�-A Street Name e-1-'S <br /> Cm L-o—+krU LDca }, +-iOvt STATE ZIP <br /> ZOq-71L -46K � <br /> PHONE#1 EaT• APN# LAND USE APPLICATION# <br /> (SID ) 30 9 -0135 <br /> I PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C <br /> r)a ase <br /> J(� l CHECK If BILLING ADDRESS� <br /> BUSINESS NAMEPHONE# E. <br /> Na n q �eGi {�`l rs ii n l D o n wi- Q0 3 0 y_q 3 <br /> HOME or MAILING ADDRESS &�O Town <br /> Com^, FAX# <br /> J O ( ) <br /> CITY �+ r () STATE C-ft ZIP a S 33 O <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,STATEand FCALE' la <br /> APPLICANT'SSIGNATURI r DATE FP. Io 13, 2QZ3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Er OTHER AU • RIzED AGENT[3 <br /> ffAPPLJCANT is not the B/LL/NGPARTP proofofaathorization 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. P p <br /> TYPE OF SERVICE REQUESTED: `EC 1 <br /> Fri, <br /> COMMENTS: <br /> 13 <QI� <br /> NJOAQUINC <br /> NEAO-H pEPg6N AL Y <br /> ACCEPTEDBY: �� EMPLOYEE ( � DATE: 2 ( 23 <br /> ASSIGNED TO: -LLOUC A A EMPLOYEE#: Q DATE: 12 �7 <br /> Date Service Completed (if already completed): SERVICE CODE:0 P 1 E: I60 <br /> L' <br /> Fee Amount: rt t36 Amount Paid I�1 _ Payment Date 2 13 23 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> VR65410 J <br />