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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME <br />L <br />PHONE# EXT. <br />zOe! Z97-11YO <br /><3t2 DON 48 q <br />OWNER / OPEWIM <br />FAX# <br />( ) <br />CHECK If BILLING ADDRESS <br />STATE ZIP <br />r <br />ACCEPTED BY: % L <br />T� <br />FACILITY NAME . : <br />DATE: ►1 ( a? <br />SITE ADDRESS <br />I <br />DATE: I I 1/6b J <br />Date Service Completed (if already completed): Z <br />! <br />dCo�dev <br />P ► E: 4; as <br />Fee Amount: ) S a <br />Amount Paid <br />@a — <br />Payment Date <br />l Street Number <br />Direction <br />Street Name <br />Invoice # <br />Cit <br />Zi <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1EXT• <br />�� <br />APN # <br />oo-3130.$ <br />LAND USE APPLICATION # <br />(—Y,7)7q-7-sl <br />PHONE #2 EXT. <br />BOS DISTRICT j <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR AI&A <br />I^,, r I -(f <br />o,10 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />bT vJtilFfP. Pie �v�119 C'G,Y1 pB p'o1EPv � W9pe'i Sp�31"f�scks' <br />PHONE# EXT. <br />zOe! Z97-11YO <br />HOME or MAILING ADDRESS-- j' <br />Ih�xnkd <br />CALL(209)953-7697 <br />FAX# <br />( ) <br />CITY � (✓a � <br />STATE ZIP <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 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, STATE and F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER® 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, I, the owner or operator of the property loA, <br />%he <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si T <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same l <br />provided to me or my representative. NOV t - O <br />TYPE OF SERVICE REQUESTED: UP,r : �JCG+ aJn CJ )ecoc Cotf vJ P -O% �Gl r• ri Z yDAnr <br />COMMENTS: Ve, i) (y rA ✓►Ci rec o r(J' to e,-. J ort oC ) f k 114 eS i h the ee reci <x P'faP 0--k )o "J -P iso !ME'E iy <br />Strut iJ <br />VeIlCy Gj1`,iz�h(e 4D rZPv0y II„Ps c,,d exlsMi <br />,Ytesi Ir4ke G,yl Irfor <br />+�t?Cri rlPc s'iJt�/ <br />bT vJtilFfP. Pie �v�119 C'G,Y1 pB p'o1EPv � W9pe'i Sp�31"f�scks' <br />CALL(209)953-7697 <br />FOR INSPECTION. <br />ACCEPTED BY: % L <br />T� <br />24-HOUR NOTICE <br />EMPLOYEE; REQUIRED. <br />DATE: ►1 ( a? <br />ASSIGNED TO: <br />EMPLOYEE _ <br />DATE: I I 1/6b J <br />Date Service Completed (if already completed): Z <br />SERVICE CODE: 0(') <br />P ► E: 4; as <br />Fee Amount: ) S a <br />Amount Paid <br />@a — <br />Payment Date <br />I I 2( <br />Payment Typeob <br />Invoice # <br />Check #I o3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />