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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ 5102No797 <br /> OWNER/OPERATOR <br /> JOWA COLOM6I141 CHECK If BILLING ADDRESS <br /> FAciutY NAME <br /> SITE ADDRESS ! S. WAGNF2— AVE Sf�KTA.� <br /> /J Stmet NUM I Directlon Stnret Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I I ZoI Z N• A rti`-F I r-n•NE ftp <br /> Street Number SYtreet Nama <br /> CITY C�CV STATE �^ ZIP G�SZIZ <br /> PHONE 91 •J r— Ems. APN If LAND USE APPYLIOATON# <br /> ( ) 115�- 0-70-)(0N- -� his <br /> PHONE#2 ExT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MIF-I/-6— I VTM <br /> Y CHECK if BILLING ADDRESS <br /> BUSINESS NAMEDI' ' ^,I ��_ q PHONE# ExT <br /> HOME or MAILING ADDRESSFAX# <br /> P. 073ax 2480 (z4q ) 4- z <br /> CITY 1 0D •I STATE CA ZIP q C 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 /> 1 also certify that 1 have prepared this application and that the work to be performe ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE. <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AG <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is require 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. <br /> TYPE OF SERVICE REQUESTED: PCt,4 Fid.0 E- <br /> COMMENTS: nr G`t1�/� <br /> r,G 7 2004 <br /> Gh /��^"' DEC 2 <br /> (Cola1411,Y) 3CJ Q SAN JOACtU1NENTALISf <br /> dJ VIRONM <br /> ACCEPTED BY: 'U C Iv t.O_A EM OYEE#: 2 DA7L ;—>Z O <br /> ASSIGNED TO: S`C. a EMPLOYEE M S[?Lt DA E' ? L <br /> (2 2 710 <br /> Date Service Completed (if already completed): SERVICE CODE: I S PIE: <br /> Fee Amount /e(o .Oo Amount Paid dl OD I Payment Date g r7 p <br /> Payment Type Invoice# Check# "1? 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />