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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> -' SERVICE REQUEST .i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sit ooS871 <br /> OWNER/OPERATOR <br /> I ON- .VCENr\ CHECK If BILLING ADDRESS Im <br /> FAcIunNAME C1-`r01?CV`r DF GOD CS£J£Nrt1 �Ry� <br /> SITE ADDRESS 31129 . / Nv VB��-� kv S.r-flC f�J �fS�ylS <br /> Street Number Oimction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 9I}10 'Tj(i;, <br /> Street Number Street Name <br /> CITY STDC.I-TwJ STATE CiA ZIP of Lt C) <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (2Ol 1 9 SS - 0te3S dS'71f - Off- S(o Pa - c)61 L>L)O & <br /> PHONE#2 E.T. BOS DISTRICT LOCATICQQE <br /> ( ) 7 ty <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR DP.Jt vJEt-Ct't <br /> CHECK If BILLING ADDRESS <br /> PHONE# Ex . <br /> BUSINESS NAME <br /> t_tJE 7hk GtOEf�t�oNwlENTft� 1Nc . _ -#tyq -03�� <br /> HOME Or MAILING ADDRESSFAX# <br /> 40-4- W. ONY- S - (Zoe() m9 - 03 �T <br /> CITY L—Dt> I STATE e V ZIP 415'7,40 <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 or <br /> 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGN DATE: // 3'y9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B/LL/NGPARTY 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 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. <br /> TYPE OF SERVICE REQUESTED: 10e�VtEW SD\1_ 5>V1—%&31L%T <br /> COMMENTS: /1/ie1a9 PAYMENT <br /> Pri71.�i/i (� RECEIVED <br /> n'- Nov - 3 20 <br /> SAN <br /> F NOIAONIMENTALTM <br /> ACCEPTED BY: L(,tJ�( EMPLOYEE#: O 3 DATE: �. O <br /> ASSIGNED TO: C O EMPLOYEE#: S-zi tE DATE: f/ J y <br /> Date Service Completed (if already completed): SERVICE CODE: S2,5— I <br /> P M <br /> Fee Amount: S-j5".00 1 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />