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f 1 <br /> • 0 p <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST �l <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# i <br /> 3''",OO#"/� —006"V- <br /> OWNER/ <br /> Do6fGOWNER/OPERATOR s <br /> CHECK ifBILLING ADDRESS El <br /> FACILITY NAME VF1v7- /1e.1— �rhtov,-1 1f y <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci ` Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I <br /> 0 eLp< /P/v Street Number Street Name <br /> CITY g7 c z e Cr-�� STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I l t/�� 3� 6 093 —�u� —0J-• afof 3.291-IV u/' 703ef.5I � <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE 3 <br /> I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR �tf/JW S' L V A CHECK IfBILLING ADDRESS 1 <br /> BUSINESS NAME PHONE# EXT. <br /> I <br /> FoTZD 'd' C ioN A62093 <br /> HOME Or MAILING ADDRESS FAX# <br /> 39 E cxcF011-2 C� ST, CIRO ► 33 q- 41l5C0 <br /> CITY d1 STATE CA ZIP ��L[® <br /> A� if • T <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE and FE laws. is <br /> II 3 <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNEIt� O ERATOR/MANAG ❑ 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 located at the 1 <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 /> TYPE OF SERVICE REQUESTED: a <br /> COMMENTS: PR/L L /i✓ 10CRA1//'— <br /> L��� !✓EG•�- U-'✓ %/,'� <br /> Oe i r-ry e.. L!— �^'t e( � j o_GlF-- ,v:, X—2�i— �j sf� L 2 2011 <br /> 21 MAO/�I <br /> �� j lOAOVIt4 <br /> ACCEPTED BY: s�/ ,^P 'fes` / L EMPLOYEE <br /> A$SIGNED TO: �!�� O��-' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: q4D <br /> Fee Amount: Amount Paid Q,3&4,_&r—> Payment Date <br /> Payment Type Invoice# Check# 9 8 Receiv d By: <br /> EHD 48-02-025 +� S S �� 3d�. ..00) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 t <br /> I <br />