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TYPE OF SERVICE REQUESTED: <br />L 5elOgiu—ri f /v/feexi-tr- Gem/74(4, \-0 <br />COMMENTS: PAYN <br />RECE <br />MAY .1 ( <br />SAN JOA•Ull <br />ACCEPTED BY: 6-1114 EMPLOYEE #: DATE47. <br />A H DEP <br />0 N r <br />b <br />DATE: <br />( <br />ASSIGNED TO: <br />.2-16',//a—C (A) <br />Date Service Corn leted (if already completed): <br />EMPLOYEE #: <br />SERVICE CODE: q2/3 1 E2242,0 ,2,,, <br />") Fee Amount: 43,0 g Amount Paid 4 0 3 - Payment Date <br />Payment Type Invoice # Check # <br />1-}0' li- Received By: yra <br />NT <br />VED <br />2021 <br />COUNTY <br />ENTAL <br />RTMENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />skocinfrcto <br />OWNER! OPERATOR <br />(AA6L- 24-izA // <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />ie (4 <br />677-140) Street Number 1 Direction ,) I LC4)6reet r6.1re t--) G -L4z-- 'zci-s5 - p Co e <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />/4/7 Tc,---,/ ( i Street Number Street Name <br />CITY , STATE ZIP <br />PHONE #1 #1 EXT. <br />( ) <br />APN # <br />005 — 3C1 0 -3 1 <br />LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDREExSTS <br />P <br />. <br />BUSINESS NAME / <br />/l i <br />/ <br />A/a/W) ,-//Cil 0 rl (_ 001,_c2 / , <br />HONE # <br />ac9) .32- 417-39 7 <br />HOME or MAILING ADDRESS, <br />, C A eCe9 ire' r <br />FAX # <br />CITY 6...... 6 7- STATE,- <br />C--- 4 <br />ZIP <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 F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT 0 <br /> <br />1914l 1? ri/ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)