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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />(f5) 'des I re, <br />FACILITY ID # <br />S1260q990SM <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />/111cor Co (Oct „...e161 4--i'er ty. -1..._ CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 74 2 ‘,, <br />Street Number Direction <br />Cavil 0 .egt 4-e y ed. <br />Street Name <br />.-.ke,c14-00-v. <br />City <br />q 52e, 0 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CrrY STATE ZIP <br />PHONE #1 Err. <br />( Ca 5) (-/ 1 1 --- / 40 31_ <br />APN # <br />1 9-1-15e -0 /e, <br />LAND USE APPLICATION # <br />PHONE #2 Err. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />A <br />Al e-,,e....ele, I ICC A C 0 'be t... <br />REQUESTOR LI lc -I...e t tvrz____ CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # Err. <br />( C1ZS/ trir 1 <br />HOME or MAILING ADDRESS 2_62a (cAv ptnt-i-e.- e d . <br />FAX # <br />( ) <br />CITY STATE ell. zip 1 Sz 0 A <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, TAT and FEDERAL laws. <br />APPLICANT'S SIGNATURE: km-P 01,A41( <br />PROPERTY / BUSINESS OWNER 04 OPERATOR / MANAGER OTIIER AUTHORIZED AGENT 0 <br />If APPLICANT 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. <br />TYPE OF SERVICE REQUESTED: V e i V Co a ei e c ,i li n b I aeiAl 3 ves:/- 170,2f.; t it. sepf i 4 ikilk' PAYMEN <br />COMMENTS: <br />c ei <br />1-1$ <br />RECEIVE <br />II (dog) qs3 -76q7 ID .5( heauE )As pe C 1-ib Y I - <br />DEC 2 3 202 <br />hull r ci (=Nance mile 4 feTU)te SAN JOAQUIN COUI <br />ENVIRONMENTAI <br />HEALTH DEPARTME <br />ACCEPTED BY: .„--Z--- EMPLOYEE #: DATE: i Rio 2,470 at) <br />ASSIGNED TO: DA EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 (..; i P/ E: <br />Fee Amount: 4 L 0: Amount Paid Payment Date i 7._./2, -2.„,. 2_,-L, <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003