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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R D I(o DLI LI 6 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t CsRSPT�o�1 F R OD <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME I_ I24t <br /> SITE ADDRESS 40; <br /> 1 ; V 7�GlVL �c-' <br /> streat Number I Direction Street N e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number S]reef Name <br /> CITY STATE zip <br /> PHONE#1 E><r• APN# LAND USE APPLICATION# <br /> (51o ) Zc 9— 9500 lZ0-A- 0i (3 <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4 v't CHECKIf BILU GADDRESS11 <br /> BUSINESS NAME U' `\J `tom` PHONE# E1 r. <br /> 334-2332 <br /> HOMEor MAILING DDRESS FAX <br /> 0. ox ll ( ) 34-ao2 <br /> CITY I A. STATE C44C zip �SZ"[t• <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 applic • and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT�EtiCudkn, &CQEO <br /> IfAPPLicANT is nol iheB1LLINGPAR7Y.proofofauthorization m sign is required rime <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. <br /> TYPE OF SERVICE REQUESTED: Plan review <br /> COMMENTS: <br /> sav ?`0 <br /> miKe�mSen� • Cot7lCaS4920f�i2- H Eiy)gRQUtyC <br /> FACTy�;,Al' N]Y <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: II-I-7-To <br /> ASSIGNED TO: Maribel Flohrschutz EMPLOYEE 3361 DATE: 11-16-20 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br /> Fee Amount: 456 Amount Paid c f�� 10Payment Date <br /> Payment Type ` Invoice# Check# 16 cy Z <br /> b7p Receiv d By: <br /> EHD 48-02.025 <br /> /r•I4 /S7,O SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />