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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SRVICB �_E$T� <br /> OWNER/OPERATOR <br /> Roses V " 1.dnz- CHECK If BILLING ADDRESSf <br /> FACILITY NAME J <br /> SITE ADDRESS 213 joLcK5on1 Ave nbe oi-r 1572p <br /> Street Number 0 redia. Street Name city <br /> I ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) '2c)30 <br /> 2 U 30 {�5� 6 1$Sire 6d Zq <br /> Street Number l/ I Street Name '("�tT <br /> CITY re� $TATB IF qlre f y 0 <br /> PHONE#1 En. APN# LAND USE APPLICATION# 7 <br /> (ro9 ) Std- 5 3 50 <br /> PHONE#2EZT. BOS DISTRICT LOCATION CODE <br /> ( zo ) 4 S-N6F <br /> 11 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> OC ✓h5WIP 2, CHECK If BILLING ADDRESS <br /> BUSINESS NAME •J� PHONE# Ems. <br /> 6c'Y d'-tct-5 044x- # 2 c I F1 S- 5 3 30 <br /> HOME or MAILING ADDRESS FAx# <br /> 2036 6a5 6•-a Svt, Ad s' c $ 29 1 ( ) <br /> CITYo ye 3 STATE ZIP 75 b <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, ST TE a d FEDERAL laws. 9 <br /> APPLICANT'S SIGNATUREy�r DATE O 2./Z// 2 S <br /> PROPERTY/BUSLNESSOWNER XEHATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <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 environmentaU '[e assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: '"+ �� p *3 <br /> Al <br /> TAIEt1tr <br /> ACCEPTED BY: EMPLOYEE#: Z3 DATE: /�4 'y <br /> ASSIGNED TO: EMPLOYEE#: 1 ' ` Q DATE: Z3 <br /> Date Service Comp1 ted (if already completed): SERVICE CODE: V V 'I^ 1 P1 <br /> 7�i 1r(9 <br /> ro <br /> Fee Amount: S Amount Paid I�P�— �yPayment Date 2 -2-2-1 12 3 <br /> Payment Type624 d) IInvoice# 5-IV�QBB� Received By: <br /> EHD ^ vo�o�O SR FORM(Golden Rod) <br /> REVISEDSED 1111 11/17/2003 �r�,y 11 <br />