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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALT&EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MQ v 4 L <br />FACILITY ID # <br />COMMENTS: <br />SERVICE RE <br />UEST # <br />SvG� P��a <br />DDR SO <br />ooS� 02 <br />S,e�Ivl�G r <br />DEC 2 0 20 0 <br />OWNER / OPERATOR g <br />HOME or MAILING ADDRESS <br />Q <br />CHECK If BILLING ADDRES <br />FACILITY NAME <br />SAN JOA JOAQUIN <br />HENTH DEPAR L <br />SITE ADDRESS�'1S"3orf <br />SSttreettNumber <br />Dlrectlon <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />reet Name <br />j�,7��j <br />CI ZI Code <br />CITY / <br />Street Num ber <br />Street Name <br />CITY 72LIc�Z <br />STATE <br />e;, ZIP <br />PHONE #1 EXT. <br />(may, 7q94 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( G) 75 '7� <br />BOIS DISTRICT <br />� <br />LOCA ION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />MQ v 4 L <br />COMMENTS: <br />11-7 /����� ©l ,J/ ' r <br />1• <br />CHECKIf BILLIN <br />DDR SO <br />BUSINESS NAME � <br />PHONE # <br />DEC 2 0 20 0 <br />ExT. <br />HOME or MAILING ADDRESS <br />Q <br />O <br />FAX # <br />SAN JOA JOAQUIN <br />HENTH DEPAR L <br />3S'7 <br />(Lo� <br />36 � /r <br />/ <br />CITY / <br />STATE /',p' <br />ZIP <br />Date Service Completed (if already Completed): <br />ntLwtNG AUKNVWLEDGEMENT: 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 'th 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 al SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,STATE and D"', <br />h s. <br />APPLICANT'S SIGNATURE: DATE,�:[[ 2 U <br />PROPERTY/ BUSINESS OWNER❑ PERATO /MANAGER OTH AUTHORIZEDAGENTxf, CO/✓ /'2/fC' fir: <br />If APPLICANT is n e BtLL/N PARTY proof of authoriza ion to sign is required Title <br />AUTHORIZATION TO RELEASE INFO ATION: When applicable, I, the owner or operator of the prope located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUs a assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the ame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: (��� <br />MQ v 4 L <br />COMMENTS: <br />RECEIVED <br />DEC 2 0 20 0 <br />O <br />SAN JOA JOAQUIN <br />HENTH DEPAR L <br />ACCEPTED BY: OLLv�t.d._A <br />EMPLOYEE 032 / <br />DATE: <br />ASSIGNED TO: I"0 L,I— <br />EMPLOYEE#: 0227 <br />DATE: ( Z_p I Io <br />Date Service Completed (if already Completed): <br />SERVICE CODE: oaq <br />I P I E: <br />Fee Amount: 3 (o & -rO <br />Amount Paid <br />'s 6 <br />Payment D <br />e U <br />(O <br />Payment Type t/ <br />Invoice # <br />Check # I(S <br />Received By: <br />EHO 48-02.025 SR FOR (Golden Rod) <br />REVISED 11/17/2003 <br />