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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F I OT E L bb 134 33 S <br /> OWNER/OPERATOR <br /> H A R P A I EH LLC, CHECK If BILLING ADDRESS <br /> FACILITY NAME n I L RD-TE L INN �) (S U I T EcS <br /> SITE ADDRESS <br /> &LI9, 3 Irl fjANNE� i20 tpOJ , (A g5a� <br /> Street Number Direction Street Name Cit Zip Cod. <br /> HOME or MAILING ADDRESS (if Different from Site Address) (�, I //��j� <br /> b, AU UT N 01D, 601T"L IIeffi Number Street Name <br /> CITY'r�U 115-8 &J A1C�A/9ENTU, CA STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> (115 ) 813- 8.10b <br /> PHONE92 EXT. BOIS DISTRICT LOCATION CODE <br /> (�tt(,)3on 888`► <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that 1 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, Aru and FFDERAL laws. <br /> APPLICANT'S SIGNATURE: '% DATE: DJr S5 aU� <br /> PROPER'r1'/BPNINI.SS Ov\',N'EIt1Ll �OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ 0i -1 A G 1 rt tj F`I E M8't <br /> If.,1 CVLIr:I.\'1'i.v not rhe BILLIA'G PdRT1',Proof of author$ation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 HEAL'TII 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: RE <br /> COMMENTS: D <br /> t �j MAY 25 ?021 <br /> CV wq& of d�n�Sl�l�O HE NT"I COUNTY <br /> H OFPARTTAk <br /> ACCEPTED BV: n e EMPLOYEEM Ott <br /> DATE: <br /> ASSIGNEDTO: C/ EMPLOYEE#: O DATE: <br /> Date Service Completed (1f already completed): SERVICE CODE: 0101 11 PIE: �'Vv <br /> Fee Amount: `'7 .W Amount Paid ! Payment Date Szs <br /> Payment Type ��� Invoice# Check III ' gs�o3I�, I Receive By: <br /> EHD 48-02-025 /p�� tiCJ <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V no V) Meji 0. 1n <br /> �C.��Z�03�y <br />