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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q-0Shp� :::] N OO (0(0'��Z S o(.Pw <br /> OWNER/OPERATOR <br /> � LkCA j ��,,I /` CNEprHBILLING ADORES3O <br /> C.l T V j/�Q,(1hA••�h <br /> FAciurY NAME <br /> 'TT-%e FL', g(.Ipuge ,Zia L. <br /> SITE ADDRESS /S-d y, ,^ ,1 / /1 S��/� �• n /t-1� <br /> 8aatl Number i V V V / H- e / I•�.l <br /> HOME Or MAILING ADDRESS (H Dliferent from Site Address) <br /> utreet Number $b9el N e <br /> CIT' STATE ZIP <br /> PHONE#1 EXT. APNR LAID USE APPUCAnONY <br /> U�cq ),3o r - wayCo <br /> PNONE#2 Exr• SOS DISTRICT LOCATION CODE <br /> (J o9) �9`/ (oD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESToR <br /> 1t'J`Il.� �G�f/K-4nr� CfeEartR <br /> BUSINESS NAME II1� / PINIrE{ err• <br /> �i — Cpt�Q "',— Lf^ J' BOq SAY— 0.76 <br /> HOME of MAILING ADDRESS SSU Al. A1'1nA Av4 5-k •SIO FAX# <br /> CITY �.�„^1jy7 STATE LA ZIP 41�5-766 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FElaws. <br /> T' <br /> APPLICANS SIGNATURE: 6 FEDERAL DATE: <br /> PROPERTY/BUSINESS OWW"X OP TOR/MANAGER O OTHER AUTHORIZED AGENT 13 <br /> IjAPPLICANr is nat the BILLING Pi prooJojautharization to sign is required title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �J <br /> Comlem: CCc/ T <br /> OFA? <br /> 8 <br /> Sq N✓OgQU1 Z� <br /> NF,yCV/Ro 'v C0 <br /> ACCEPTED BY: EMPLoYEE$. DATE: ?y <br /> ASsIGNEDTO:G'. 4;:;- v EMPLOYEES: �7 `� DATE: ( 2 —'L� — <br /> Date Service Completed (H already completed): SWCE CODE 00 PIE: D <br /> Fee Amount: ' l 45—Z Amount Pai • Payment Data <br /> Payment Type Invoice# Check# S— Received By: <br /> EHD 4802-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��� 5- -7® S' <br />