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SAN JOAQUII OUNTY ENVIRONMENTAL HEALTH IPPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />D 2-2 <br />FACILITY ID # <br />SERVICE REQUEST # <br />c-2fl5 Sr{':TLo a3 <br />PHONE <br />�f0 � <br />0 9 <br />HOME or MAILING ADDRESS <br />118D QOLLk, ArU-e, <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />CITY <br />STATE Ci� <br />ZIP <br />FACILITY NAME J 0. <br />Paid J \s 6b <br />Payment Date \VI 2LL 1 p S <br />SITE ADDRESS <br />Invoice # <br />`T_ `,�(� A <br />lZ9- 'Tc 7�VpCP--t <br />U61 <br />t� ao <br />6a� <br />Street Number <br />Drectlu <br />Street Name <br />C t <br />Z <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) Sq 0 <br />-{-ONf PL�� 5 0- <br />d <br />�'l• <br />Sheat Number <br />net Name <br />CITY <br />CIL5/l� <br />STATE ZIP�-12- <br />(,C <br />p I I g <br />PHONE#1 EXT, <br />APN <br />LAND USE APPPLICATION# <br />PHONE #2 EXT. <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR G L�,^I� r^ <br />D 2-2 <br />CHECKH BILLING ADDRESSO <br />BUSINESS NAME` <br />,S -v (G2 St-a_iic LA S s- -e tk, Tits- <br />PHONE <br />�f0 � <br />Ezt. <br />a t-3- w-3 r <br />HOME or MAILING ADDRESS <br />118D QOLLk, ArU-e, <br />FAX# <br />Mk7) <br />/ <br />ai3-C�O�(v <br />CITY <br />STATE Ci� <br />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: �Ua"Xt 1,1, ' � l e! t L (Q�A�> DATE: <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENT'Z &d klplte:U-C(. b-FET.c <br />1fAPPL/CANT is no1 the B/LL/NG PAR proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. _ ^ o R1 n <br />TYPE OF SERVICE REQUESTED: U S I <br />D 2-2 <br />/� , ` <br />(�o <br />COMMENTS: �q-��CACt�lsQ-I ` UC -EEPV oL LL.) COC DEL rl L1 )OUo <br />-`-� .v ) Z <br />�,WIF ptytJlEif�'IiEFLTN <br />PERNAIIISER`1lGE a <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0� <br />P I E: law <br />Fee Amount: -)Amount <br />Paid J \s 6b <br />Payment Date \VI 2LL 1 p S <br />Payment Type 1 <br />Invoice # <br />' 21 Lo ;4 Check #!t <br />Received1 By: <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />SR FORM (Golden Rod) <br />q N i <br />