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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR i <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ADDDRESS I.• VT DV)�Woaa P` cKf 9S?IQ <br /> Pg30 Street Number Direction I Nem. Cit ZI Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 31rea Name <br /> CITY STATE ZIP <br /> PHONE#t ExT' APN# LAND USE APPLICATION# <br /> (aoq 01- 9-?131, Li m <br /> PHONE#2 EZ. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOt;,, <br /> iaVi �/tt�ta�}o CHECK If BILLING ADDRESS0 <br /> BUSINESS NA E PHONE# E.T. <br /> TTeLatmoay, eoo4- svot. (aoib mrCibb-12,1313 <br /> HOME Or MAILING ADDRESS FAX# <br /> (ao9) S45- Y44/ <br /> CITY CQI;SCL STAJE ZIP 053(99 <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. i <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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: V�luglt 'AA, DATE: /0 �/ 7/&) <br /> PROPERTY/BUSINESS ONNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED ACE 'e <br /> /fAPPLICANT is not the BILLING PARTY Proofofaatttorizatioittosignisregnired Thle <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. �J c <br /> TYPE OF SERVICE REQUESTED: P00)Iedmode) F <br /> i <br /> COMMENTS: OC , <br /> T 19 I <br /> �T� FuHASA <br /> RTy/ <br /> i3 <br /> ACCEPTED BY: Vidal PedraZa EMPLOYEE#: 6213 DATE: 10-19-20 <br /> ASSIGNEDTO: Vida) PedraZa EMPLOYEE#: 6213 DATE: I0-19-20 II <br /> ii <br /> Date Service Completed (If already completed): SERVICE CODE: 523 PIE: 3602 iI <br /> Fee Amount: 304 Amount Pai 361-OQ Payment Date <br /> Payment Type Vi 6�,_, Invoice# Check# //S'7o3)1-7 Recei dBy: <br /> / /lSz 361/ <br /> EHDSED 11/1 / oI I4' SR FORM(Golden Rod) f <br /> REVISED 11/17/2003 1 <br /> / zl [CV 26 JDA �r 3 00l <br />