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SAN JOAQUI*UNTYENVIRONMENTAL HEALTH 9ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property I FACILITY ID # <br />se'e'64(tt' <br />SERVICE REQUEST # <br />--¢Ne At Si re 4 C.45 5YA7101-FA&347 <br />12-c"4 a cc <br />OWNER/OPERATOR , <br />'` <br />Eglite <br />CNECKI}BILLING ADDRESS <br />Pte# <br />FACILITY NAME <br />/ <br />SITE ADDRESS <br />�t�-�f Act/ <br />7�f�' <br />LP <br />`i52o3 <br />��yy <br />-T Street Numlrer <br />Direction <br />Street Na <br />D <br />i <br />HOME or NAILING ADDRESS (N Different from Site Address) <br />EMPLOYEE #: 5 ` <br />Street Number <br />DATE: <br />Street Name <br />CITY " STATE <br />zip <br />PHONE 91 W- <br />9 <br />APN4LAND <br />59 <br />USE APPLICATION# <br />Date Service Completed (if already completed): <br />f25�:4) 31- 4 o <br />n,7 <br />G <br />PIE: S ?!e <br />PHONE #Z Ea. <br />( ) <br />SOS DISTRICT <br />Amount Paid J L) <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />se'e'64(tt' <br />CHECK if BILLING ADDRESS <br />�SNeL-L <br />BUSINESS NAME�w�® ? t. i _ <br />Pte# <br />HOME or MARIINe ADDRESS <br />/ <br />FA%# - <br />"Cn) <br />CITY <br />STATE L.A <br />LP <br />`i52o3 <br />6 <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, Standar x TE and FEDERAL laws. �[.. <br />APPLICANT'S SIGNATURE: DATE: �A D S� <br />r-- <br />PROPERTY/BUSMM OWNED OPCRAToR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />IfAPPL1CANT is not the B1LLINGPAHTT proof ofautborizadon to sign dx required rule <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 />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. ._ AcNT <br />TYPE OF SERVICE REQUESTED: I (T ! N (T <br />se'e'64(tt' <br />PN I '�1vElJ <br />COMMENTS: <br />1 '1005 <br />SPd 30ovkNMEt�nENf <br />N�THOEPPI< <br />ACCEPTED BY: <br />OL(V CI i0� <br />EMPLOYEE #: 5 ` <br />DATE: <br />ASSIGNED W: <br />L E <br />EMPLOYEE #: 3 5 f <br />DATE <br />Date Service Completed (if already completed): <br />SERVICECODE: <br />G <br />PIE: S ?!e <br />Fee Amount:% <br />q o J <br />Amount Paid J L) <br />Payment Date "1 I t O — <br />Payment Type <br />`/ <br />Invoice # <br />I <br />Check # i -f -C) F0 ( <br />I Received By: <br />EHD 4M2-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />