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f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NER 1 OPERATOR <br /> � CNECK if BILLING ADDRESS <br /> FACILITY NAME ; Vel <br /> //t PSdICf'G2.ti <br /> 517E ADDRESS d 0-f"4-1 /-, j �t G ��r; Q ft�f�.� U�-' If <br /> 9-NstreetNumber Dinar an • �—'• ' C� ZI Cade { <br /> HOME or MAILING AoDRESS (if Different from Site Address <br /> Street Number Mroot Name <br /> CITY STATE ZIP f <br /> PHONE M Err. APNi# LAND UsE APPLICATION# <br /> ( l A`73--491 <br /> PHONE Q EXr• 7 <br /> OS DISTRICT LOCATION CODE <br /> CONTRACTOR! SERVICE REQUESTOR <br /> R>=ctu ESTOR <br /> San Joauin County Aging and Community services CHECK if BILLING ADDRESSQ <br /> BUSINESS NAME PHONE# Ex' <br /> (209)46&3895 <br /> a <br /> HOME or MAILING ADDRESS <br /> PO;Bax 201056 ( 1 <br /> c'rr Stockton STATE CA ZIP 95202 <br /> BILLING ACKNOWLEDGE NT: 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.IOAQufN <br /> COUNTY Ordinance Codes,Standards,STATE and FERAL laws. <br /> AI'PUCANT'S SIGNATURE: '� ��.f�-�-�vt Sy4 DATE: <br /> PRQPERTY t BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O=R AUTHORIZED AGENT❑ <br /> If APPLJCAAT is not the BILLING PA,R 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 /> i <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: d-r" G S ca EMPLOYEE#: DATE: <br /> I <br /> Ass1GNED TO: `./G EMPLOYEE#: DATE: <br /> Late Service Completed (if already completed): SERVICE CODE: D� PIE; <br /> Fee Amount: ��` Amount Paid Payment Date <br /> Payment Type SS Invoice# Check 14Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />