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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �' I, <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Aniceto Ruiz CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS 27 S. Del Mar Avenue Stockton CA <br /> Street Number (rection Street Name city zipo <br /> HOME or MAILING ADDRESS (It Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> 2091 933-0870 - Sylvia (daughter) 159-035-03 x.41 <br /> `47 <br /> PHONE#2 Err• BOS DISTRICT 7 <br /> LOCATION CODE <br /> 1 1 '2- <br /> CONTRACTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A--J CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> 209 473 <br /> HOME or MAILING ADDRESS FAX# <br /> 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,STA and FEDERAL laW. . <br /> APPLICANT'S SIGNATURE: DATE: 7 <br /> PROPERTY/BUSINESS OWNER 1A OPERATOR/MA GER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,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 /> f <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S-Lk ,Q�� JA-TLD <br /> l COMMENTS: //�/ �� / PAi`/M <br /> �,"t7k�Ia� / o <br /> RECEIVED <br /> CJI.i= x a 4U G 2 4 2007 <br /> Cly��J <br /> SAN JOAQI}1N COUNT`( <br /> APPROVED sy:. L�1.u�{ �/ EMPLOYEE#: . DEPART TE: �.L <br /> ASSIGNED TO O F n TMJ EMPLOYEE#: DATE: `! <br /> Date Service Completed (If already completed): SERVICE CODE: js I'/E. 2&03 <br /> Fee Amount: 0 nt Paid � f Payment Date 's <br /> AmouV -1 <br /> Payment Type' ✓ . Invoice# Check#, j Q Z� Received By:1/1 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />