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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �° (1 W— 4�' FAm�17584 SR0a84 3 4 <br /> OWNER/OPERATOR iGVI moi' H / _ <br /> !/�t ✓ �--0 (l7 l� CHECK If BILLING ADDRESS <br /> FACILITY NAME C �>M 6N L <br /> SITE ADDRESS <br /> e SS <br /> 1 i 1 ZS h t umber DlrecHon Street Name <br /> Cit Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Add-r7ess) <br /> Street Number G Street Name <br /> CITYSties W" `1 STATEI� ZIP T i—� ' n <br /> PHONE#1 x E . APN# LAND USE APPLICATION# <br /> (9i6 ) o o s-) <br /> PHONIER E". BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ii <br /> 1�Y 4-4g� l-p.;V CHECK If BILLING ADDRESS <br /> BUSINESS NAME /L PHONE# EXT. <br /> C.�t�rHilti Zl RIf tr7_}I.u. -t' /�� <br /> HOME or MAILING ADDRESS FAX# <br /> CIN ¢ / STATE ZIP 64 11 j O' <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Q�II DATE: G/-- <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER p OTHER AUTHORIZED AGENT 13 <br /> I'APPLICANT is not theBgLlNG PARry 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme�Lnttaal/sites ,�ssment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ImPAYrMMIme it is <br /> provided to me or my representative. I RECEIVED <br /> TYPE OF SERVICE REQUESTED: /70 S U L +�Lfi On JAN 14 2M <br /> COMMENTS: <br /> SAN COUNTY of ownership- ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C . QI/�ahrl EMPLOYEE#: DATE: <br /> ASSIGNED TO: V i d of ?ed ra Z 0. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE. 1(D®a <br /> Fee Amount: Q� 15 a Amount Paid it (sz _ Payment Date ) <br /> qtr y Yl '�iv 2 2- <br /> Payment Type j S l2 Invoice# Chea# ?) D Z 5S) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ���� r_0 <br /> r,3 <br />