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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST lb <br />Type of Business or Property <br />BUSINESS NAME �1 v�%/i/ ` <br />FACILITY ID # <br />HOME or MAILING ADDRESSq G I S /V Tom/ jZJ� <br />SERVICE REQUEST # <br />p -s <br />d 3 �/ <br />DATE: //12-2 <br />2 2 �v <br />ASSIGNED TO: 921- <br />OWNER/ OPERATOR .�. <br />_5A AlP H �V �� <br />j� <br />L (�L C <br />Gj <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME -(j uN?eEy S)nC <br />14I;V, M,4 e ; <br />Fee Amount: �C�- VZ)Amount <br />SITE ADDRESS I IAC)7 I N 144 F <br />g -S L-0 CA q �` � 40 <br />Payment Date -IA b? <br />Street Number Direction <br />Street Name city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />`I�/ <br />Received By: <br />3 10 0 GSL- S i 011 &/A <br />Street Number <br />Street Name <br />CITY /VI flO }� <br />f (l 6 <br />C TE <br />ZIP C) c <br />J <br />PHONE #1 EXT.• <br />Ll <br />APN # <br />LAND USE APPLICATION # <br />PHONE #T 7 T <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j�V, S/Xlq ! S'7�-/Vp / E]t 1 / I CHECK If BILLING ADDRESS <br />BUSINESS NAME �1 v�%/i/ ` <br />QEXT' <br />PHONE # <br />HOME or MAILING ADDRESSq G I S /V Tom/ jZJ� <br />FAx # <br />CITY MD ®12S �b STATE ZIP 0) <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, STATE and FEDy laws. <br />APPLICANT'S SIGNATURE: DATE:7 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLiNGPAR TY 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 enviromnental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aud at the same time it is <br />provided to me or my representative. '91' <br />TYPE OF SERVICE REQUESTED: i�•S �� n/� L jj �O� <br />��E <br />COMMENTS: <br />Wy q <br />SAHJp ` 9 200, <br />H q QviN <br />�CTyo pqR �OF /y�Y <br />ACCEPTED BY: (� t V t <br />EMPLOYEE M <br />d 3 �/ <br />DATE: //12-2 <br />2 2 �v <br />ASSIGNED TO: 921- <br />EMPLOYEE M <br />p rr <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P E: <br />Fee Amount: �C�- VZ)Amount <br />Paid g, <br />Payment Date -IA b? <br />Payment Type C4 <br />Invoice # <br />Check # <br />� <br />Received By: <br />EHD 48-02-025 SR FOt fvT (Golden"Rod) <br />REVISED 11/17/2003 <br />