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SAN JOAQUI4OUNTY ENVIRONMENTAL HEALTH W ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I►0 Fa <br />FACILITY ID #' <br />rkooiw <br />SERVICE REQUEST # <br />5 0033-151 <br />A <br />PH,Of E� <br />ExT. <br />4 t_ 2D' 4 <br />C� <br />HOME or MAILING ADD ESS <br />Lu C1e.fn 2 <br />OWNER/ OPERAT64 <br />ar ) �( 1al ^ <br />CHECKIfBILLINGADDRESS� <br />�L•Ae� Owonri gk5eo /�_ 6rnr0., <br />I J (� G� <br />FACILITY NAME <br />^ ` � /4 ^ � <br />K <br />t, I' <br />SITE ADDRESS "( 115' 1 <br />a G f c- e,. <br />q520-7 <br />Straet Number Direction <br />Street Name <br />cityZi <br />Code <br />HOME or MAILING ADDRESS (If DHiP-..* frorTT Site Address) b �6 S �rOO t ej5 Lk-C'rc <br />_ <br />Street Number Street Name <br />CITY !' � <br />(� <br />STATE � ZIP <br />PHONE #1 EXT. <br />(201) L}? 3 -I 1'l _I <br />Payment Type <br />APN # LAND USE APPLICATION # <br />110 - 2-3o - I <br />PHONE#2�'u Exr. <br />(IM ) <br />SOS DISTRICT <br />71 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r , r� II �#1e L 1 <br />•lY\ wT C <br />CHECK if BILLING ADDRESS 19- <br />BUSINESS NAME &1 u i vi eer! e <br />COMMENTS: <br />PH,Of E� <br />ExT. <br />4 t_ 2D' 4 <br />C� <br />HOME or MAILING ADD ESS <br />Lu C1e.fn 2 <br />0 1 -?A <br />FAX* <br />lav ) <br />44-3565 <br />CITY c � <br />STATE C(Q. <br />ZIP 45M3 <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 applica' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST and FE RAL laws <br />f Q <br />NATURE: <br />DTE: <br />PROPERTY /BUSINESS OwNERIl OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, 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. PAYMENT <br />ter, <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />MAY - 9 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY:Mi <br />0 1 -?A <br />EMPLOYEEM `�Z�`L <br />DATE: 5-� - 0 <br />ASSIGNED TO: <br />m . ±e , <br />EMPLOYEE M 3 5 O 0 <br />DATE. ,- 9 - 03 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 3 <br />P / E: -2 30 <br />Fee Amount: 5 3 <br />Amount Paid <br />S3 <br />Payment Date Z)3 <br />Payment Type <br />Invoice # <br />Check #I S3 <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />