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SANJOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6R/La t-rWA 2E5/vEn/TIAL �✓ �6 <br /> OWNER/OPE <br /> /�fIS o.V/ STOKES CHE(?1Ue1NQUDRESS11 <br /> FACILITY NA <br /> _ OKE ✓rl �vi� <br /> SITE A7SOo WE5 <br /> Street Number Direction Street Name cityZi Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 5 Iryl Stre¢t Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> Vol) 7,14 - 2slS 00/_ /90 -/ FA - o& -6-7 <br /> PHONE#2 E'tT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� w , <br /> V 0/V CHECK if BILLING ADDRESS <br /> BUSINESS NAME J PHONE# En' <br /> C IFSNFt 60,4J S ULTin/C 6G 9, 1403 <br /> HOME or MAILING ADDRESS FAX III <br /> a • eov 3-7 24 98 <br /> CITY r R STATE 6 ZIP <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 apTp, fon and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST d FEDE ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ O EA AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of aath ization to sign is required Titre <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 REQU TED: EX PED/TED So/ Su/7R a/L / 57_W e REV/ <br /> COMMENTSy 1T EIVED <br /> A�%NAL 7 <br /> p <br /> SAN�jD ^'Warn ��jj ENV <br /> ACCEPTED BY: EMPLOYEE#: ,Pim DATE:HEA <br /> ASSIGNED TO: EMPLOYEE#: tt���� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:JC yz yvI PIE. 0 / <br /> Fee Amount: ' v' Amount Paid Payment Date i i I, _ ; C <br /> Payment Type Invoice# Check# Received ey:. <br /> EHD 48-02-025 ' R FOFtM( rofddnRod) ' <br /> REVISED 11/17/2003 <br />