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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `�A � 15�2Cp Sr2 5q <br /> OWNER/OPERATOR Ghanem PCHECK If BILLING ADDRESSO <br /> okmmrl <br /> FACILI AM v�hOaaA "I( LP <br /> SITE ADD SS 1 <br /> �IjIE Ir^� S L <br /> e �ber Direction � Stree am9 � ' CI n "& ZI Code <br /> HOME or MAILING ADDRESS (If Different from,Site Address) <br /> 5Q1 / tom--, Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EzT. APN# LAND USE APPLICATION# <br /> ) 510-3bS79q� <br /> PHONE42 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ IM I t� <br /> (1 1 1/1 ✓ 1/�111/�/t IM O�/Im ��t CHECK If BILLLLIIING ADDRESS <br /> � <br /> BUSINE NA E _ ,� Y�f v�1 tP \\ 1.1 1 C.I r tMa�l. l/ UUGT� 1 PH E <br /> HOME orMAILING ADDREss1 3� N. ,�^ o / n ��- FAx# L5 <br /> rY `wL ( ) <br /> CIN STATE zip gs33 <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - _ — - DATE; 123 ZO Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT LJ <br /> IfAPPL/CANT 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 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: e41 tu ` 14RECEIVED <br /> COMMENTS: LAPR 2 3 202, <br /> �G111G1�, �1 dv�V��51� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: D 23 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com eted (If already completed): SERVICE CODE: I E: <br /> Fee Amount: 15 2— Amount Paid S Payment Date 1,617 <br /> 2 <br /> Payment Type Invoice# Check# Received By: AV <br /> Y IV <br /> 25 j " SR FORM(Golden Rod) <br /> REVISED <br /> 1111/17/2003 <br /> ` N <br />