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,. ✓ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CALL (209) 953-7697 <br />\r, <br />P-0, n <br />FOR INSPECTION. <br />J �Z <br />24-HOUR NOTICE <br />OWNER / OPERATOR <br />CITY (. Z�t7� Cyd STATE ZIP <br />REQUIRED. <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />-� <br />, <br />A" sa4W1e. 715!1} <br />SITE ADDRESS <br />Z2-L L <br />- d 16s7a9, Of bedrooms feY+^--- ir►S <br />t1,A 1 L f( -1st\ <br />llyie J r1f, vom <br />Y_ �� r> C <br />C j j L-3 f' <br />Street Number <br />Direction <br />Str et Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />EMPLOYEE #: <br />DATE: ,-2117122 <br />Street Number <br />Street Name <br />CITY <br />P / E: q d 0a <br />STATE ZIP <br />PHONE #1 ExT• <br />( <br />APN # t <br />C)C130 0Lla <br />LAND USE APPLICATION # <br />2 2"v 2- <br />-2 --Payment Type <br />Invoice # <br />PHONE#2 ExT• <br />Received By: <br />BOS DISTRICT (^I <br />LOCATION CODE <br />( ) <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />C <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />❑ <br />/ <br />1 L `� ,� l v w ` � �`'` � C .; %✓l (--1 �- L �- CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHQNE# ExT. <br />TYPE OF SERVICE REQUESTED: <br />HOME or MAILING ADDRESS <br />FAX # <br />COMMENTS: <br />CITY (. Z�t7� Cyd STATE ZIP <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 />1 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: 2Li7f -Z Z_ <br />PROPERTY/ BUSINESS OWNER PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required MUM E NT <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the "GF1Vfi0at 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 arl6lihj �hi*k�ie it is <br />rovided to me or m re resentative <br />P y p <br />TYPE OF SERVICE REQUESTED: <br />ENVIRONMENTALH <br />EALTH DEPARIMENT <br />COMMENTS: <br />- <br />�G-'+L <br />V <br />-� <br />, <br />A" sa4W1e. 715!1} <br />T Devi Gt'/� li{�,r1 o), P" <br />- d 16s7a9, Of bedrooms feY+^--- ir►S <br />llyie J r1f, vom <br />exlsepi,4 <br />VerIPeC/ <br />ACCEPTED BY: �Zr J�� ��1 _ <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: ,-2117122 <br />Date Service Completed (if already completed): <br />SERVICE CODE: o('` <br />P / E: q d 0a <br />Fee Amount: +i Ca <br />Amount Paid <br />(S-2.— <br />Payment Date <br />2 2"v 2- <br />-2 --Payment Type <br />Invoice # <br />Check # 7j �j <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />