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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTHIPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property I II FACILITY ID# SERVICE REQUEST#,� <br /> C i f O ` I c LIC t T \U 96 <br /> OWNER/OPERATOR ECK If BILLING ADDRESS❑ <br /> t S<06C <br /> 1116-7 rT <br /> FACIUTV NAM �T <br /> 1/1i�2 L <br /> SITE ADDRESS <br /> Street Number Directloo treat Name Cit ((�' Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 4Z5� a, �. `�O Va�1a Si. �V41100r <br /> Street Number t at Name <br /> CIT,IS <br /> STATE ZIP <br /> PHONE#1 q )� EXT. APN# LAND USE APPLICATION# <br /> ) 1 <br /> (U 1i1 - 1 154 270—Q S? <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (n� 1 - CHECKK BILLING ADDRESS <br /> 1TUb �NH T V.,t t�-l��N <br /> BUSINESS NAME PHONE# EXT' <br /> CST m - _OeA. \n fZ "'�Uy7 'l T-- <br /> HOME <br /> —HOME Or MAILING ADDRESS FAx# <br /> CIN S.�-V �`� STATE L61 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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,StandM.BILLINGA <br /> AL laws. <br /> APPLICANT'S SIGNATURE: DATE:PROPERTY/BUSINESS OWNER❑ ER THERAUTHORIZED AGENTIf APPLICANT is noOOf of 1 rization 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. 1 q <br /> TYPE OF SERVICE REQUESTED: vlS( U�-.l?i.>,. L^ (,o< , l? N NT^ 'F"�Q l <br /> COMMENTS: <br /> RUSH <br /> NOV 19 2008 <br /> Sw JDAODIN COt4mFO� USH <br /> ��,, ,,AA EM1tRDEPAR EKI <br /> ACCEPTED BY: (� L-(V F( ter( EMPLOYEE#: 3.y/ DATE: <br /> ASSIGNED TO: VOA) EMPLOYEE#: $3 t '7 DATE: It (IG 8 <br /> Date Service Completed (if already co ted): SERVICECODE: O3 P I E:,2,,30 <br /> Fee Amount: s/5' Do x(, —= ount Paid L�� 2, S t7 Payment ate <br /> Payment Type Invoice# Check it $ Received By: N�� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />