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ncucivt:u <br /> Y <br /> SAN JOA0IN+C'OUNTY ENVIRONMENTAL HEALTH DFPARTMEN�EB 2 6 2008 <br /> SERVICE REQUEST SAN JOAQUIN COUNTY <br /> Type of Business or Property FACILITY ID# SEA H L <br /> AV t o 1 Te_-r ct,,�a ENT <br /> } ®9 <br /> OWNER/OPERATOR <br /> 01-ex CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> / 87 {f: 19 r1 'Cy-) <br /> SITE ADDRESS <br /> Street Number Direction Street Name city ZI Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Numher Stree <br /> CITY t Name <br /> STATE Zip <br /> PHONE#1 EXT. APN# / LAND USE APPLICATION# <br /> I *, <br /> PHONE#Z EXT. BOO DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR f SERVICE REQUESTOR <br /> P+ <br /> REL�UESTOR //'�� J��.. {�'J�y'� n <br /> �.L+CJi�( �.J!""J- •. /T CHECK if BILLING ADDRESS <br /> BUSINESS NAME VrI5 � . PXHI # 3 . 0758 <br /> EXT. <br /> HOME or MAILING ADDR S5 FAx# <br /> CITY r f�C NATE /'�M\ ZIP I C7C✓ / <br /> BILLING ACKNOWL DGEMENT: 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 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: j DATE: 119 46 C& <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER �- <br /> 0 OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PAr?TY.Proof of authorization to sign is required 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 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 REQUESTEM"ke pare- (1) 3 `X pq ':5jr�1ex �.0 «!Lt'k �.� <br /> COMMENTS 0 P�101Cc- 1 e- <br /> t f � 5 N t-+ of-P Ua.We. � �7 c��onrl eCf U A t+cm ; <br /> rti A lt-o k n -S r0. .�cxl5 . ��'%�`'- 'tc�r'n { arr ✓C+tl i1QC'e �i C t Y S <br /> ClY t-tr�� tray �t �ra3t Rzi'�r�toue— L1�3'X O.`c : t ey- Une <br /> (ex L1'r&3`�X:N= tcel <br /> c'trn neC f L.111 i On . (fir i I r I E Liv xit, 'e-1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EM <br /> #: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P I E:' <br /> Fee Amount: Amount Paid } Payment Date Z <br /> Payment Type ✓ Invoice# Check# Received By: I I <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />