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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />NOV 2 2 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT- <br />EPARTMENTACCEPTED <br />SERVICE REQUEST# <br />L,Ac, SMIoJ I� <br />mmt <br />FAX # <br />. <br />/R,EQUEST <br />5;1M "` ` 01 Zo <br />OWNER/ OPERATOR <br />PSL- <br />4v0(,L 1A11 ON M at")CE <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME WIL&L'J <br />woo CfhW?'0' ( <br />Amount Paid <br />SITE ADDRESS Lf 1+- <br />N..6>ILsLV'3 0#4 <br />Sib0cw `(SLCS <br />Street Number <br />Direction Street Name <br />city Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address), <br />be <br />2'{i 17 <br />Street Number <br />Street Name <br />CITY <br />�hRTil':il� <br />STATE (,A ZIP gl�fs �f <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />( IDi- ) I'loi <br />_ <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />( i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR PAuL_ -JuVC- 'giiN Hr <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME w1acy t ti -m L <br />NOV 2 2 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT- <br />EPARTMENTACCEPTED <br />PHOS# EXT. <br />c(y2 - 23'f `f <br />HOME or MAILING ADDRESS <br />4%+tJ wiLS.�nt wAy <br />DATE: <br />FAX # <br />. <br />DATE: \� • D <br />( 2,)1 9lf l- -23u6 <br />CITY STV -X UJ <br />STATE CA ZIP jS2sas <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 or <br />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, STAT-& d FEDERAL laws. <br />APPLICANT'S SIGNATURE: <� DATE: 11)2a- 1us <br />PROPERTY / BUSINESS OWNER Ltl OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BiLLINGPARTY 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. PAYM E N T <br />TYPE OF SERVICE REQUESTED: <br />LVED <br />COMMENTS: ,. / _ � _ Q ClL� ^ � <br />NOV 2 2 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT- <br />EPARTMENTACCEPTED <br />ACCEPTEDBY: b �Z 4 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: VZ�.EMPLOYEE <br />#:Kf <br />DATE: \� • D <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0`(A <br />P 1 E: <br />Fee Amount: p��✓. <br />Amount Paid <br />Payment Date \\112_1§ 5 <br />Payment Type L� <br />Invoice # <br />Check # 3 3 <br />Received By: <br />EHD 48-02-025 ',SR FARM"(Golien Rod) <br />REVISED 11/17/2003 <br />