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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH NPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />�'o�.w� y -�'.✓� -s�io <br />FACILITY ID # <br />SERVICE REQUEST # <br />CG vS E -D 6A?-r✓kol^l e C- <br />9 -.fig -- rn0 3 <br />SP -0 0 <br />67 119 <br />OWNER/ OPERATOR <br />S�/e' ✓�r�QG�,� <br />_ <br />��rlt/, r �, ��8ut` `j//�s ����%� W��f�NEC If 61 IN ADDRE 13 <br />FACILITY NAME <br />P I E: Z/ C) % <br />Fee Amount:3 ��'= <br />SITE ADDRESS <br />Payment Date <br />Payment Type S $' <br />Invoice # <br />pt� <br />Street Number <br />Direction <br />tre t NameZio <br />city <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) /'?/0 <br />e- 05`-�� -670^1 /- 1/e - <br />Street Number <br />Street Name <br />% _ ,� / <br />STATE el'; A ZIP <br />9sa as- <br />sPHONCITY%C <br />E #1 EXT. <br />PHONE <br />('20) e6 1? -36% <br />APN # LAND USE APPLICATION # <br />0 6 5 - o 30 -03 <br />PHONE #2 <br />( ) <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />�'o�.w� y -�'.✓� -s�io <br />PHONE# E.,�/pui.✓ <br />�6� -sem 6 <br />HOME or MAILING ADDRESS <br />bio E /�ZG Giv/✓ <br />FAX# <br />( ) <br />CITY ��j� tJyl� STATE ZIP �11a,t57 <br />BILLING ACKNOWLEDGEMENT: 1, 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, STATE and FERE L laws. <br />APPLICANT'S SIGNATURE: DATE: 1.4-1140V�'-Y <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT � '-qo `j ��» li✓�1 �� <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is require Title CA';p'V- t;R, <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 t0 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://��L L /wi,� �i /y! // r� ��'�c C//L�✓ <br />COMMENTS: �RIGLI/✓Yl�/ %I•l!/ ig� <br />/t/��i/ ��ll�/�/i) G✓/�-i��i2 /1�1r/y✓/iC/h'�i✓r j L✓�CS -T Svu; M <br />ACCEPTED BY: /� _ V� <br />EMPLOYEE M W g 0 <br />DATE: <br />ASSIGNED TO: A/4 77; , ,9 <br />EMPLOYEE #: e16 9 --)DATE: <br />�519113 <br />Date Service Completed (if already completed): <br />SERwCE CODE: Soo <br />P I E: Z/ C) % <br />Fee Amount:3 ��'= <br />Amount Paid 3-�5 <br />Payment Date <br />Payment Type S $' <br />Invoice # <br />Check # �jj� <br />Received By: <br />Se7tp o D 10 17 <br />EHD 48-02-025 5A,4" SX�ORM (Golden Rod) <br />REVISED 11/17/2003 ��3/ �/ 3' ��d'e!1'"'f' w' tle' wcC� iC�-4� �+,•� yyt y� _ 3 Aw _ Y S <br />`�3 / t'3 da �uv-v� �s n •+� �.✓�-G( '��-�C.v� o., v - Y„V 3 A!3/�' - yam• <br />