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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />FACILITY ID # <br />P NE# EXT. <br />31- 2(vS�o <br />SERVICE REQUEST # <br />#: <br />'A <br />) 3I qq L4 <br />CITY i '�e 0 <br />STATE CAv� ZIP <br />EMPLOYEE #: <br />SONTI12- <br />OWNER I OPE TOR <br />�� <br />V`. Y �r/ 1^ '�W�.Y�V�ei <br />}�. <br />�tAvc.t <br />n <br />CHECK If BILLING ADDRESSE] <br />FACILITY NAME <br />Amount Pa' S.2 Dd <br />Payment Date 1 <br />Payment Type c ' <br />Invoice # <br />Check # <br />SITE ADDDRESS1Av` <br />Received By: _ <br />fI�/ )///�/i ►�[��}��I <br />�' <br />�-M 2 <br />ie J I� Street Number <br />Direction <br />`�� I Street NamEs <br />�v ' Gt <br />Cod <br />HOME Or MAILING ADDRESS Different from Site Address) <br />-1 <br />V, Q- el � 1 <br />Street Number <br />Street <br />Street Name <br />CITY <br />L)nde+n <br />STATE ZIP <br />G44V 1�7-52 3Co <br />PHONE #1 <br />(7p�j) 6131- 2(�`CP <br />EXT. <br />APN # <br />�1- DZC - ��2 <br />LAND USE APPLICATION # <br />-I o `t � <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR r <br />REQUESTOR A\ _ I n 1 �(\1 ,1 <br />�j`I Vi" y� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />ACCEPTED BY: <br />P NE# EXT. <br />31- 2(vS�o <br />HOME Or MAILING ADDRESST , ROX rl 11 <br />#: <br />'A <br />) 3I qq L4 <br />CITY i '�e 0 <br />STATE CAv� 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 />activity will be billed to me or my business as identified on this form. �y <br />I also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JO� � %^/- <br />COUNTY Ordinance Codes, Standards, STATE an ED RAL laws. <br />APPLICANT'S SIGNATURE: DATE:I�1 SAN✓ C I9 <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR f MANAGER LM, OTHER AUTHORIZED AGENT ❑ y� �7R �7NC �0�� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title FP^ /v <br />qR Tq�H�Y <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abovW41h' <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />71 <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: D <br />COMMENTS: <br />Ilr �i F1ff'r c�r�`'!r' q)TG�irzw <br />Ei�L ,�" rf • " �' �Z.t�' Vd^ ' C/ �� fi �% %IPJ �'N' � 2 /�7 LC.-�S S �U I /l%C7 <br />fire— <br />_ACCEPTED <br />ACCEPTED BY: <br />EMPLOYEE <br />#: <br />DATE: <br />ASSIGNED TO:Wb <br />oo <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 6 <br />P I E: Z <br />Fee Amount: 5 <br />Amount Pa' S.2 Dd <br />Payment Date 1 <br />Payment Type c ' <br />Invoice # <br />Check # <br />Received By: _ <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />0 <br />