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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rt'( J 1,10'r C' 1 -<;f, 00 il,!L2 3 <br /> OWNER/OPERA OR <br /> V. I�� IO� <br /> FACILITY NAME � CHECK if BILLING ADDRES <br /> �/�GN. li/t V 'T /� �041� n �] <br /> SITE ADPRESS �-i r1LV'eN %s23�o <br /> /I �S—Street Number Direction 1'J'z'C2t2r Stree1�-C1t Name CRY Zi Code <br /> HQ or MAILING ADDRESS (If Different from Site Address) <br /> C'(9• VOX 711 Street Number Street Name <br /> CITY STATE ZIP <br /> Li'"de', Ca. C/52! o <br /> PHONE#1 FXT. APN# LAND U E APPLICATION# <br /> 1 ) DbS -110 — D� �i4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l ) 1 O O `/cl <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �r uode <br /> CHECK X BILLING ADDRESS El <br /> BUSINESS NAME ExT. <br /> t7; l �o10'-) � P <br /> gHONE# 33 q — &6( 3 <br /> HOME Or MAILING ADDRESS FA%# <br /> R a. Pox 2(ao ( ) <br /> CITY Lm'CT STAya ZIP 9S 2-z// <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 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, AT d FEE L law/s�./yjD -711,2,/l <br /> APPLICANT'S SIGNATURE: �M" � ` DATE: <br /> rrr 3 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENTIK <br /> /f APPLICANT is not the BILL/NG 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 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: dm=z PAYMENT <br /> C <br /> COMMENTS: F"IfED <br /> n/1 1 D/Z l/13 ryt N <br /> b/VW JUL 2 2 <br /> web SAN JOAQUIN COUNTY <br /> ENVIRMENTqL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: rn dJ pr EMPLOYEE#: 24 DATE: -2 <br /> ASSIGNED TO: D EMPLOYEE#: N- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 ZZ PIE: �D <br /> Fee Amount: ZSR Amount Paid Payment Date -714-?-- 13 <br /> Payment Type Invoice# Check# Received By: ,. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />