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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />S900-74st:�=J <br />OWNER / OPERATOR CHECK if BILLING ADDRESSO <br />FACILITY NAME <br />SIT A DRES <br />r -�- -Street Number Cin I�"✓_T Street Nam' �� �itv - - Z—gin C 11 • j <br />I Ho+•,'E or, MAILINC ADDRESS (If C"fferent frot.:; Site Address)) —� <br />Street Number :,reef Name <br />CITY f STATE,- ` ZIP <br />Y.v�-� <br />/ P IJE F� <br />i �4 <br />EXT. APN # LAND USE•LICATION # <br />P ' <br />E, SOS DISTRICT Loi N oor- <br />CONTRA OR / SERVICE IC REQUESTOR <br />RE JESTOR <br />�,�__ CHECK it BIL! '.GA`.DG.�G_S <br />/ BUSINESS NAME PH NE # EXT. <br />LQIA� <br />r /, <br />HOMEQr AILING A ESS�� Adz lAX# ' �s�l� <br />/I CITYIr�J' — STATE ZIP — <br />f=ifLLfiry ri�+I�IVLsrrLcuyClncly 1. I, Litt: UIIUel�flfIICU PIUPUILY UI UU5I111eS5 Uwner, operator Or autnonzea agent or 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 form. <br />I also certity 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 SIGNATURES DATE:� <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require��Tia <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at t'r, aba <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment inform0n. Y•M A, <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is provided t0 me 6r k Yl <br />my representative. M ��%Fo <br />TYPE OF SERVICE REQUESTED: <br />L� <br />SqN d <br />COMMENTS: <br />fi <br />L,. � <br />� a � 2 t waw <br />C< � (�� � � . (�L �� L . , <br />�) <br />t <br />ACCEPTED BY: <br />L:MPLOYEE #: <br />DATE: lel 261Ai <br />ASSIGNED TO: !A ��- <br />EMPLOYEE #: <br />DATE: <br />Date Service CCmp.!,:ted (if already completed): — <br />SERVICE CODE: <br />Fee Amount: <br />Amount Paid <br />Z,b U Payment Date <br />Payment Type Invoice # _ <br />Check # 20 S Rec ved By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />