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PA2100146 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S17 Jv <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> ; Webster Williams <br /> FACILITY NAME <br /> SITE ADDRESS E FEight Mile Road Linden 95236 <br /> 17337 Street Number Direction Street Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 1477 Street Number Street Name <br /> CITY Linden CA STATE ZIP 95236 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (818 ) 205-7399 065-100-45 <br /> PHONE#2 Exr. BOS DISTRICT L LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Tristan Hartun CHECK if BILLINGADDRESS� <br /> BUSINESS NAME P209 � <br /> Dillon & Murphy 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY I adSTATE CA ZIP 95241 <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 FE RA VS. <br /> / <br /> DATE:APPLICANT'S SIGNATURE: _ l2�?�t►� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGEROOTHER AUTHORIZED AGENTa Party Chief _ <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 /> t i , <br /> TYPE OF SERVICE REQUESTED: Sir ��,�.� C�)�C S()i5u 1 re94C (}�Y �C,I� I��' wOr� r2PD;(� <br /> COMMENTS: <br /> � 3 2021 <br /> SAN JOAQUIN C <br /> HSA TH 01i j)'rojPARV/RolvmsTIAL 1?' <br /> ACCEPTED BY: ��J�`'L= EMPLOYEE#: DATE: -7 <br /> ASSIGNED TO: I p EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S a 3 P/E: <br /> Fee Amount: �(Dl-1 I <br /> Amount Paid U0 H,--- Payment Date 7�7- (3I <br /> Payment Type QkuoInvoice# Check# 2 3-9 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />