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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t-�Ote.k <br /> '5)p—lxu-Ta� '9S l <br /> OWNER I OPERATOR SOY1.1 + poll <br /> r1'ttr i.V1 � � � �j k(+y�Q CHECK IfBILLING ADDRESS <br /> �yI <br /> FACILITY NAME 1- 2, S IiAf-S h4 H;Nan Trekcj <br /> SITE ADDRESS -025 U estT Crf r,�l 4-tn2 �Lo C.� -7- I City <br /> Street Number Dlrectlon Street Name Cit ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) 103 LO.n 5k i4"1f e#V4 <br /> Street Number Street Name <br /> CITY / STATE ZIP q{B0 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# I <br /> (209 ) 619-1013 244- 020- 31 <br /> PHONE#2 Exr, SOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �&ASfilUC J M kV1JA�US 1AC CHECK 1f BILLINGAoDRESS13 <br /> BUSINESS NAME SL,.� Do I_i.,E PHONE# EXT. <br /> 1 t� V J 5S 7 30'1 a <br /> HOME Or MAILING ADDRESS 5320 PJO t"--) 9 6/W S FAX# <br /> ( ) <br /> CITY (to STATE c q ZIP 9 3'11-2— <br /> BILLING <br /> `12ZBILLING 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 /> I also certify that I have prepared this application a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an DERAL laws, <br /> APPLICANT'S SIGNAT RE: DATE: <br /> PROPERTY/BU51,�lE55Ow(tER OPERATOR/MANACFR ❑ OTHER AUTHORIZED ACE:IT❑ <br /> If APPLICA,N,r is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propem 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: <br /> COMMENTS: <br /> A6oV o <br /> H N�o�QU�N8,SINZ01B <br /> EacryD pAco cN <br /> ACCEPTED BY: EMPLOYEE#: �� DATE: r`f <br /> gh <br /> ASSIGNED TO: Q 'V��.2� EMPLOYEE#: e-1 DATE: J <br /> L L <br /> Date Service Completed (if already completed): SERVICE CGDE: PIE: <br /> b <br /> Fee Amount: Amount Pai tS6. �� Payment Date f �� <br /> Payment TypeU/�� Invoice# ch7k# �7,3 Received By: - <br /> EHD 48-02-025 � �,L �� yt r � � � ]Golden Rod) <br /> REVISED 11/17/2003 f` `" " / <br /> �5A0 <br />