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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS I� <br />FACILITY ID # <br />SERVICE REQUEST # <br />lIom <br />HOME or MAILING ADDRESS <br />3570 E. Mtvrer Ave- <br />RoNgr� () <br />OWNER / OPERATORf <br />STATE A LP A? 2o <br />ACCEPTED BY: W,I/)r Lam, <br />✓ <br />(Qmmoyl <br />CHECK If BILLINGAoDRESS� <br />0.0.. Service,5 <br />l.W <br />Rn <br />FACY NAME <br />ASSIGNED TO: S"'� 11 <br />EMPLOYEE <br />DATE: <br />ll 117-12 <br />�?I <br />Date Service Completed (If already Completed): SERVICE CODE: 5� <br />WE ADDRESS IW13ovJ <br />Fee Amount:'U Amount Paid 0 Payment Date <br />, <br />thd�a,mmL(l <br />Payment Type <br />01.) <br />954?09 <br />Street Number <br />Dlreotlon <br />Received By: <br />Sbyet Nam <br />C <br />D C <br />HOME Or MAIUNO ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 En. <br />(20) 507 - 150 Hsi <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Ear. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR C'cvSioojo v 2 <br />CHECK if BILLING ADDRESS I� <br />BUSINESS NAMEy. <br />! <br />Ttic a NL ae I <br />��'?.9 <br />PHONE# En. <br />I6 713- go66 <br />HOME or MAILING ADDRESS <br />3570 E. Mtvrer Ave- <br />NeW VP i0 code- and rdtls AD 6G 4-ty <br />'ki'mci�lT�N <br />��D <br />FAX# <br />( ) <br />CITY Si(x 1l <br />STATE A LP A? 2o <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 at work t be performed will be done in accordance with all SAN JOAQt1tN <br />COUNTY Ordinance Codes, Standards, URE: STATE RA lawV <br />APPLICANT'S SIGNATDATE: <br />P/—,St <br />LN <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER r <br />OTHER AUTHORIZED AGENT I> r LSt ky, I <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is require 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 environmentausite assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s it is <br />provided to me or my representative. �i7q <br />TYPE OF SERVICE REQUESTED: 1g - P 1a5fi e j <br />a.i <br />CoMMENT3. ExtSi;+)�J paal A0 be, tfG-rlas+e <br />EHD 48-02-025SR FORM (Golden Rod) <br />n <br />REVISED 11/17/2003 I ko "Oot I <br />rc,l <br />��'?.9 <br />tjw Uf io Cnu{ 4 IArtxw. CL7,ie AO be, 10sit'Alled <br />,y✓oROrNpFMN/NFNC U <br />NeW VP i0 code- and rdtls AD 6G 4-ty <br />'ki'mci�lT�N <br />��D <br />� <br />�rMFa <br />Nodi dceo,, wov k fj 0. (d `safety law, { I le, to be- i H3+*rNe-ta <br />ACCEPTED BY: W,I/)r Lam, <br />✓ <br />EMPLOYEE#: %7V <br />DATE: <br />II �'�l <br />ASSIGNED TO: S"'� 11 <br />EMPLOYEE <br />DATE: <br />ll 117-12 <br />�?I <br />Date Service Completed (If already Completed): SERVICE CODE: 5� <br />P IE: <br />OZ <br />Fee Amount:'U Amount Paid 0 Payment Date <br />, <br />Payment Type <br />invoice # <br />Check # I e-0 <br />Received By: <br />EHD 48-02-025SR FORM (Golden Rod) <br />n <br />REVISED 11/17/2003 I ko "Oot I <br />