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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS ;1ANAME <br />NM'iS <br />000()9q1P <br />SW'1001�10 - <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �1„uL W'f\LAA S <br />SITE ADDRESS 15`('�Ce'YJ <br />l r <br />S -r <br />� <br />LC��I <br />��� 4Z <br />JV 1 treat Number <br />Dlrectlon <br />Street Name <br />Cit <br />L Code <br />M�tAtILINI,G, ADDRESS (If Different from Site Address) <br />DATE: 10 1-3 /JL <br />1�� <br />wkor <br />(ia IV N 1 1� <br />Street Number <br />Street Name <br />CITY <br />No Yoe fel <br />S TE ZIP <br />C � Ci533& <br />PHONE#1 Ex . <br />APN # <br />SERVICE CODE: <br />LAND USE APPLICATION # <br />(S61 ) 33 1 -) � (9 <br />Fee Amount: I ll/ <br />Amount Paid <br />PHONE #2 Em <br />Payment Date D zj Lp 2 2 <br />BOS DISTRICT <br />LOCATION CODE <br />(3151, ) 6063103 <br />Received By: <br />EHD 48-02-025 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR1_^ ' <br />LLI <br />CHECK If BILLING ADDRESS <br />L Y ` y <br />TYPE OF SERVICE REQUESTED: <br />BUSINESS ;1ANAME <br />NM'iS <br />PSbi pJ '(S 6j' Exr. <br />HOME Or MAILING ADDRESS <br />FAX# <br />w4 N Ain Sr <br />( ) <br />Cm A <br />STATE . ZI 3 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: A DATE: �D A? 2 2 <br />J'ROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTUER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authoriZatiOn t0 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 environmental/site assessment <br />inforrllation t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is availahlr, P"Tne time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />OCT <br />OAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />C�)MV, OF QW170rS 1 i <br />ACCEPTED Y: IAO <br />I <br />9- <br />OYEE M QQ o <br />IlU-l0v <br />DATE: 10 1-3 /JL <br />1�� <br />ASSIGNEDTO: S <br />y1I 6 AESMPLOYEEM <br />DATE: ♦� <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: �0'L <br />Fee Amount: I ll/ <br />Amount Paid <br />/ <br />Payment Date D zj Lp 2 2 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Pf�ol (a234Z <br />