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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �k5 4r�/ �/ G-Sf�r� �AOOISZ-7 S-P, 009LA 1?V <br /> OWNER/OPERATOR <br /> y -p- .M iA TWG CHECK If BILLING ADDRESS <br /> FACIUTYI" 'tNAME /C'j7�/ L .L�—5, L <br /> SITE ADDRESS 1117 �y�H rrl, �r T 57OGr`T04 R.�yo6 <br /> Stmt NumberDirection Street Name city zip <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number S re t Name <br /> CITY STATE zip <br /> PHONE 1H E7 APN# LAND USE APPLICATION# <br /> (yoi ) 379-8081 ( b -q5-0 - 6700 <br /> PHONE#2 Ev. BOS DISTRICTO O' LOCATIO11 ON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR JTHr-^7N Tt�A, - dee kr- Wrno0)M PJC,G r� CHECK 1f BILLING ADDRESS <br /> BUSINESS NAME PHONE Exr. <br /> SHeu T,--5 yob 3zT- 9091 <br /> HOME or MAILING ADDRESS7/z Ia/ Gz� (.� SrnnrY FAx# <br /> VV G G� ( ) <br /> CITY Sznc -T STATE CL zip �SaO,6 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sane, <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 an DE L laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER V OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization 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 HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. el <br /> TYPE OF SERVICE REQUESTED:O lt"4V 6r- o tdat,5fi zP <br /> COMMENTS: <br /> SEP o <br /> 1 <br /> hE4�7) Q(J/tv <br /> ACCEPTED BY: EMPLOYEE#: DATE: /� FNT <br /> ASSIGNEDTO: Wy EMPLOYEE#: DATE: ✓ <br /> Date Service Completed (If already completed): SERVICE CODE: P I E: <br /> Fee Amount: I�2� Amount Pa DIV /i� l)U Payment Date 9 Z <br /> Payment Type V, /3077/631 <br /> Invoice# Check# /�`�e7 Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />