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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> E� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST.# <br /> OWNER 1 OPERATOR <br /> 1"�A�t p I p CHECK If BILLING ADDRESS <br /> 11�� <br /> FACILITY NAME <br /> SITE ADDRESS 2��� p���S �L qp►� L OD! �SZI�Z <br /> Street Number Direction Street Name Ci ZI Code <br /> y <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4z58 <br /> Street Number Street Name <br /> STATE zip <br /> ° h <br /> TY ��� C.4 q-5 24^Z- <br /> PHONE#1 EXT' APN 11 LAND USE APPLICATION# K <br /> {2A 3 Iq- �3-.pgo -per l.�.fti�SSt C��J <br /> Ex-r. BOS DISTRICT LOCAIT CEDE x <br /> PHONE#2 ( <br /> r � <br /> ' CONTRACTOR/ SERVICE REQUESTOR <br /> REQuESTOR , <br /> r , <br /> CHECK if BILLING ADDRESS <br /> F'r <br /> l3usINeSSNAME MU(Zt�t�F PHONE# 33 -6& 3 EXT <br /> x <br /> HOME or MAILING ADDRESS I S3 _o"lZ3 <br /> xr <br /> CITY \\ STATE CA zip <br /> � F <br /> 5 r - <br /> BILLING A( _ or business owner, operator or authorized agent of sa ►e <br /> acknowledge i ' . � kLTH DEPARTMENT hourly charges associated with thts project <br /> or activity willzn <br /> QVWS s <br /> om'l� - � <br /> I also certify t' S�-Y---�`°" be performed will be done in accordance with all SIN JonQ[tIN �,3 <br /> �� 1 r <br /> COUNTY Ordi <br /> APPLICAN IS �� <br /> PROPERTY BU ! <br /> ETHER AUTHORIZED AGENT❑ <br /> cation to sign is required <br /> AUTSORIZI cable, I,the owner or operator of the property located at'the s <br /> above site ad >ults, geotechnical data and/or environmental/site'assessment <br /> information to EPARTMENT as soon as it is available and at the same tlme It Is <br /> V.- <br /> provided to mg,tpe u � <br /> TYPE OF SERVIC �R cV t t�C-P 3 flit <br /> i7 LL'✓S2G y2 {G� �CJ + ' 1� ` �'� I Y•CJ <br /> COMMENTS: <br /> EIVED G� 7�� t V� <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: O L C t J I IP� I IrEmFLOYEE <br /> ff T � 3 yr DATE: L�J <br /> ASSIGNED TO: A 1 J{ #: <br /> 15-3 (o DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 S P 1 E: tv0 <br /> Fee Amount: r Amount Paid f p Payment Date � <br /> Payment Type Invoice# Check# L-d Received 8y; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />