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rD ,5 , -V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />tirotCl <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME S'FW Dabbs <br />PHONE# <br />1�0i-�1 9s � <br />OWNER I OPERATOR g <br />PMWA8 l >�-Ii-� rW clla / �AAl !P i SoJ kw, WO CHECK If BILLING ADDRESS <br />FACILITY NAME H^'oL <br />2 f tr Atg Jv t-� H -on ro cl <br />SS -1 1397-30'1'0 <br />SITE ADDRESS 2- <br />015 <br />West <br />&CO41- L-A(W Ko O.8 <br />FAX# <br />1 ) <br />FngRTMq( <br />9S311 <br />Street Number <br />Direction <br />StreN Nems <br />DATE: I <br />AsSIGNEDTO: 1<6LAta,7i1 <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 103 <br />DATE: I <br />L ,o'"'e <br />E Lo S - V �.rtA�, <br />n A <br />StmtNumber <br />SERVICE CODE: L. <br />Strea Name <br />CITY ��y�., I <br />STATE C rl ZIP 9 S 330 <br />PHONE #1 <br />(209) 619-1013 <br />APN # <br />2W -020-3°I <br />LAND USE APPLICATION # <br />PHONE #2 EeT• <br />l ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REOIJF.STOR <br />REOUEBTOR �n (�1�/t� /� (��'U_�', 'nx- IncCIIASi V � 0V\ De I SSI I <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME S'FW Dabbs <br />PHONE# <br />✓o 8 ?018 <br />SS -1 1397-30'1'0 <br />HOME or MAILING ADDRESS Sia W <br />0OH-h cui <br />.J LV I—I i <br />FAX# <br />1 ) <br />FngRTMq( <br />CITY f � . (O <br />TT � <br />STATE CA <br />ZIP 93'122 <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. <br />1 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 an EDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 1 1(S 118 <br />PROPERTY/BUSINESS OwNE^7\p'p1� OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 10 <br />If APPLICANT is not the BILLING PARTr proof of authorization to sign is required Titre <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. PA e <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />"O1/O <br />✓o 8 ?018 <br />FngRTMq( <br />ACCEPTED BY: <br />EMPLOYEEM 13 <br />DATE: I <br />AsSIGNEDTO: 1<6LAta,7i1 <br />EMPLOYEEM C -I3" <br />DATE: I <br />Date Service Completed (if already completed): <br />SERVICE CODE: L. <br />Pit: <br />Fee Amount: <br />Amount PaI <br />`�Slp L,)6 <br />Payment Date <br />% <br />Payment Type V I ISR - <br />Invoice # <br />Chpdk # � 7,3Ffj <br />Race ved By: <br />EHD 48-02A28 ��� A/u� �� o-(/•L6!-4rp�. �_U- (Golden Rod <br />REVISED 11/17/2003 /� ) <br />✓/IJ <br />