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SAN JOAQUIPT — UNTY ENVIRONMENTAL HEALTT PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ldWSaI <br />l�pt/� <br />- <br />FACILITY ID # <br />11� <br />SERVICE REQUEST # <br />S20o3-� to�- <br />OWNER/OPERATOR /) Qi <br />PHONE# <br />CHECK If BILLING ADDRE55E] <br />FACILITY NAME <br />V v t /�� <br />APR 2 0 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FAx # <br />e S <br />SITE ADDRESS 7 <br />-- Street Number <br />Direction <br />f'r33 <br />/ / 14n R <br />Lt Street Name <br />CL <br />Zia Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />PIE: 3(p D 2— <br />Fee <br />Fee Amount: <br />STATE ZIP <br />PHONE #t <br />( I <br />APN # <br />LAND USE APPLICATION # <br />PHONE#1T• _ <br />Payment Type <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /1 v <br />/-r h IF/ (�. <br />ldWSaI <br />l�pt/� <br />- <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEE' /+( <br />COMMENTS: <br />PHONE# <br />5.7 7 <br />HOME or MAILING ADDRESS <br />APR 2 0 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FAx # <br />e S <br />CITY 11 <br />STATE ZIP <br />f'r33 <br />BILLING ACKNOWLF11dME�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 or <br />activity will be billed to me or my business as identified on this fonn. <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 laws. <br />APPLICANT'S SIGNATURE: zoe f�J(J) DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />If APPLIC,[NT is not the BILGING PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: Mi✓f L,,r R---4w-LX <br />`�v 0,0l4-,fcT <br />PAYMENT <br />COMMENTS: <br />APR 2 0 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />e S <br />EMPLOYEE#: <br />/ <br />DATE: z O O <br />ASSIGNEDTO:a-jln(fl-2-1) <br />EMPLOYEE#: <br />DATE: 2� O <br />Date Service Completed (if already completed): <br />SERVICECODE: SZZ <br />PIE: 3(p D 2— <br />Fee <br />Fee Amount: <br />}jj <br />Amount Paid fp <br />6 D <br />Payment Date <br />----o o Lf <br />Payment Type <br />Invoice # <br />Check # 9,11 <br />1 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 - - <br />