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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />R <br />FACILITY ID # <br />BUSINESS NAME <br />GoJaFE :a. <br />SERVICE REQUEST # <br />S*�o�t�t�QNOF,2�tt <br />Pe1a�s <br />T-AQL/.,J <br />5 <br />OWNER / OPERATOR <br />CITY *t-Aol.l"-rA.l . 1 4V % <br />STATE ems^ zip '?S39 I <br />SERVICE CODE: 001 <br />J� Gt3'p 4v7-40GF-:-v>\1b <br />CA1�If7 <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />Payment Date <br />L/7 <br />Payment Type <br />SITE ADDRESS �TSTJRJ4 Sj. <br />Check # ��S�LZS <br />�' V tl�ITLL✓L.6 <br />S�T• <br />MI�1IhI 16Ih1 r�WSt <br />"(S 3q <br />y115 )' Street Number <br />Direction <br />Street <br />Name <br />city <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 En. <br />APN# <br />LAND USE APPLICATION# <br />(Z09) st-co-oss•3 <br />_ <br />-it <br />PHONE#2 Ev. <br />140$15 IS' ?--'N <br />BOS DISTRICT <br />6 11 <br />LOCATION CODE <br />q14 I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />R <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />GoJaFE :a. <br />tyq y Fp <br />sl J,01 2p71 <br />h� Ty N, COU, <br />O , <br />PHONE# Ea' <br />540 - $ss <br />HOME or MAILING ADDRESS <br />FAX# <br />EMPLOYEE #: <br />DATE: <br />CITY *t-Aol.l"-rA.l . 1 4V % <br />STATE ems^ zip '?S39 I <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 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 SIGNATURE: / DATE: <br />PROPERTY/ BUSINESS OWNERZ- OPE TOR/MANAGER❑ OTHERAUTHORIZED AGENT 13 / <br />/fAPPL1CANT 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. <br />TYPE OF SERVICE REQUESTED: <br />R <br />COMMENTS: <br />tyq y Fp <br />sl J,01 2p71 <br />h� Ty N, COU, <br />O , <br />ACCEPTED BY: lye �I^ �/ <br />EMPLOYEE <br />ASSIGNED TO: a a tiloS <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 001 <br />PIE: /6 D 3 <br />Fee Amount: % Z 09 <br />1 Amount Paid /S�Z Do <br />Payment Date <br />L/7 <br />Payment Type <br />Invoice # <br />Check # ��S�LZS <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />