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SAN JOAQUIW&UNTY ENVIRONMENTAL HEALTII"OliEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID III ^ SERVICE REQUEST# <br /> -i2 - ( ?fS .5/e-/J0o5(-1( jo <br /> OWNER/OPERATOR ' VGI.,..Uz,1...{ 'mss-C+ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME l � _ <br /> SITE ADDRESS qq__ � � �A tet,., p <br /> Stree[Num ber Direction treat me CI 2 <br /> ip 00" <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 157 AvL hc)r c-4- <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> C e'l Y� <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (':lol-) X30 Jam- 223 - 230-( 3 <br /> PHONE#2 En. BOIS DISTRICT LOCA O CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR 'to"i•�'��-i"' <br /> /l a..."+�'S L"P�� NEC 11 BILLING ADDRESS <br /> n..Lu.LtlL1410501-7-7 C <br /> BUSINESS NAMEPHONE# E". <br /> 1 i+� -2o`t <br /> HOME Or MAILING ADDRESS FAX# <br /> ,lZ+ . <br /> CITY C : `L J .� Cc� STATE ZIP 4.01 i <br /> BILLING ACKNOWLEDGEMENT: II, 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. C- <br /> APPLICANT'S SIGNATURE: Y- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CnN is not the B/LL/NG PARTY 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 REQUESTED: <br /> COMMENTS: <br /> JUL0010 CO"t4v <br /> 1 6 2008 <br /> SAt'ENVRONNI M�EKf <br /> HEN-TH DEPAII <br /> ACCEPTED BY: (_t✓E L EMPLOYEE#: 032-1 DATE: / <br /> 4-lo k <br /> ASSIGNED TO: (Q u_ EMPLOYEE#: -2-&70 DATE: 7' 11610e- <br /> Date <br /> / OpiDate Service Completed (if already completed): SERVICE CODE: /,?,? P 1 E: ;2' or' <br /> Fee Amount: a! O-D I Amount Paid 1�a- l q 0-0 Payment Date ") 1� 0 Si <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />