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SAN JOAQUI, :OUNTY ENVIRONMENTAL HEALTH _,PARTMENT <br />SERVICE REQUEST Q f2,05 i -)Lf B 77 Aro I �)— <br />Type of Business or Property <br />FACILITY ID # <br />T-Ao2SSocl <br />PH NE# <br />SERVICE REQUEST # <br />Sk,7- 00ti azo <br />OWNER/OPERATOR PANESNh Man,'t <br />CITY J'rn f T TO N STATE ON ZIP 15111 <br />CHECK If BILLING ADDRESS❑ <br />�t�t t•rt�1'f,f <br />FACILITY NAME M l L -& DREPtM yy L tL) 1 V W N Mit l <br />SITE ADDRESS yggO <br />Street Number <br />Dlrecaon <br />Indr A�t` <br />/1u�' <br />`Sllreel Name <br />r•t-n G1'rn►I <br />lv <br />J' V bCity <br />���A'I <br />Z10 CVodo <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I I f�QI <br />Street Number <br />EMPLOYEE#: <br />� UV (ATL tlt'V1 ul d <br />A `,Ill1��Sltrreet NWamla <br />CITY St-Oc my <br />\i <br />STATE /A ZIP Cl ry'� <br />7 L <br />PHONE #1 E"• <br />(1oq) q�l - N90b <br />APN # <br />Fee Amount: 4 `"�Z <br />LAND USE AAPPLICATION # <br />PHONE#2 ERT• <br />( ) <br />Payment Date �?-z/ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR D (� K VW D"i VI`/ CHECK If BILLING ADDRESS <br />BUSINESS NAME (�^IL .� �YI CLI <br />1� <br />PH NE# <br />HOME or MAILING ADDRESS4blq fnl <br />0�%(lFt� T•„J- WM <br />I ) <br />( <br />CITY J'rn f T TO N STATE ON ZIP 15111 <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 fort. <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, and FEDER aws. �( <br />APPLICANT'S SIGNATURE: 7)DATE: V I Z I2I <br />PROPERTY/ BUSINESS OWNER I,4 PERATOR/M)kGER❑ OTHER AUTHORIZED AGENT 11 <br />If APPLICANT is not the BILLLNG PARTY proof of authorization t0 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 environmentaUsite 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. P <br />Aliq <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: , <br />U ly-� <br />�A�G 0Z 2p <br />Oq 2 <br />H'Stilv1•LRON LN COU <br />TNpE�M( <br />FN <br />ACCEPTED BY: /I/1 0 <br />"(• V <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P t E: <br />Fee Amount: 4 `"�Z <br />Amount Pai <br />a U <br />Payment Date �?-z/ <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />