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SAN JOAQUIN COUNTY ENVHIONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST f gwbutl <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '��s 10. r��k X23225 R o o g 512,5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Manuel <br /> FACILITY NAME <br /> EL V I,(Lo Co Co �- 3 <br /> SITE ADDRESS .Z ltl2 N —F—r.,'+V O�5`30� <br /> Street Number DI.Iion Street Name CI Zip Code <br /> HOME r MAILING ADDRESS (If Different from Site Address) 1000 c-r <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> eo t'-,c9raL S ) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ZS ) V05 <br /> PHONE#2 ExT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING AOORESSEY <br /> BUSINESS NAME PHONE# ExT. <br /> olk> LJc— RZ 5 1 1-10S z <br /> HOME MAILING DDRESS FAX# <br /> c> far. I ..kie ZD(' Sr -16 22- <br /> CITY \)a.t STATE cpf ZIP of <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 ENwRONwNTAL 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 la s. <br /> APPLICANT'S SIGNATURE: I r DATE: 0Z13221 <br /> PROPERTY/BUSDNESS OWNEWG' OPE—ERATOR/MANAGER ❑ OTHER AuTHORIZL•D AGENT <br /> IfAPP/sCA,VTis not the H7L7dNG P11117Y 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. PA I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ✓ut08 O <br /> 844f 0 #21 <br /> h� TyDFqR�4NI Y <br /> ACCEPTED BY: \^ /e EMPLOYEE#: DATE:'/ %f <br /> ASSIGNED TO: `^Y C"f EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Obl PIE: 00O'2. <br /> Fee Amount: \ S2- - Amount Paid I <br /> Payment Date —Z— Z I <br /> Payment Type AMe Invoice# Check# 12'7967 / Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) / <br /> REVISED 1111712003 /�✓ <br />