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1 <br /> SAN JOACIPCOUNTY ENVIRONMENTAL HEALTH -PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE R QUEST# <br /> GIS � l-n � ���64 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME n N o <br /> i 1+ 1-) <br /> SITE ADDRESS Q <br /> Its WIISON W�� SfiIGtD✓1 �52b5 <br /> Sbeet Number Direction treat Nam <br /> HOME or MAILING ADDRESS (If Different from Site Address) .�I I Lt" y}, <br /> SVeet Number t Name , <br /> CITY `` �� STATE n A ZIP OU� <br /> PHONE#t AP # I O LAND USE(APPLICATION# <br /> �0i21 ')'eon11 - 3 -DI <br /> PHONE#2 FXT. BOTS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -'t Kf1 IN <br /> lol CHECK if BILLING ADDR <br /> BUSINESS NAME t PH x # <br /> TUfb a : pn . <br /> HOME or MAILING ADDRESS) � Ibn p- FAx) HCl tX �2�1 <br /> CITY CNn I lo C v` STATECA- ZIPe'11-1001 <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 Or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this appli t' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA a Id EDE Claws. <br /> APPLICANT'S SIGNATURE: DATE: Le� <br /> PROPERTY/BUSINESS OWNER❑ OPERA /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILL/ PARTY proof of authorization to sign is required S Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me Or <br /> my representative. r^� <br /> TYPE OF SERVICE REQUESTED: Sr Pr �D <br /> COMMENTS: 04` 2013 <br /> p�G J l <br /> SAN JOA OMENOMEN <br /> PJ- <br /> HEp j'CN DEPpR <br /> ACCEPTED BY: �,�p�f��� EMPLOYEE#: (,7 DATE: f <br /> ASsIGNEDTO: ,V r I , EMPLOYEE#: �l(i %>4 DATE: <br /> Date Service Com d (if already c pletad): SERVICE CODE: 0 3 PIE: Zap <br /> Fee Amount: 4 S Amount Paid4 Payment DateVzL-17 <br /> Payment Type Invoice# Check# Re ived <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 I IC <br />