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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 />Sf�DOg5220 <br />OWNER/ OPERATOR Va Lt j rvl/y) Aag <br />( <br />CHECK If BILLING ADDRE55O <br />FACILITY NAME 1.. ac j V 't— <br />7- �- <br />I o�,ec 7q f 4 _o C 1 v f O <br />rT(J JT CL ) <br />SITE ADDRESS / 2 <br />Street Number <br />\ o / <br />Dlrecaon <br />1 OC / p ve <br />t_ Streeett.N`ame <br />EXT. <br />7- qQ0q <br />I' <br />py <br />ZI COYV <br />HOME or MAILING ADDRESS (If Different from Site Address) q -> 5� <br />COJ Street Number <br />y> 15L/ (1 <br />IA"1 / r1 Street Na me <br />CITY [-6 /d <br />/ry <br />(.•) STATEC ZIP Z)v <br />7 <br />PHONE#t T• <br />(2VT 7'4 - n09 <br />APN# <br />CITY tiDd t <br />LAND USE APPLICATION If <br />PHONE#Z En, <br />( ) <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR 'jam <br />BILLING <br />CHECK If BILLING ADDRESS <br />'J <br />Lvtn r <br />VL <br />Fri f <br />? �OT <br />QUIN <br />BUSINESS NAMEPHONE# <br />c4c+u <br />s <br />ow•err 1 <br />o d <br />EXT. <br />7- qQ0q <br />HOME or MAILING}iDDRESS <br />FAX# <br />q 77 <br />Ave. <br />EMPLOYEE #: <br />( ) <br />CITY tiDd t <br />STATE CAZIP <br />ACKNOWLEDGEMENT: I, the undersigned properly 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, STA and F ERA �j �J <br />APPLICANT'S SIGNATURE: DATE: ✓ m Z 22 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORizEDAGENT❑ <br />If APPLICANT is not the BILL/NG 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environm'Ye�nt�a'Usite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an me time it is <br />provided to me or my representative. R�+4 /_�IiE/VT <br />TYPE OF SERVICE REQUESTED: AV _ C 1 Fi) <br />EHD 48-02-025 BR FORM (Golden Rod) <br />REVISED 11/171 <br />COMMENTS: <br />Fri f <br />? �OT <br />QUIN <br />Q <br />M�.M p�� <br />T <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: S . _ <br />EMPLOYEE#: rj <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 061 <br />PIE. yl(] <br />Fee Amount: ,y <br />Amount Paid <br />Payment Date 5 Z 2 2 <br />Payment Type <br />Invoice # <br />C e <br />7J <br />I �lXl <br />Received By: <br />2003 <br />