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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR H(^ ^ OI r,DGA G ► ticil <br /> }x J CHECK If BILLING ADDRESS <br /> FACILITY NAME f P—Esfl SLICC— PIZza>\ 10 c— - may.„ L,p� �T <br /> SITE ADDRESS k$9� s• LyTE 99 S� ,�,V c.k•�� pal <br /> Stree[Number Direction Street Name City Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ti 10"1 G U LD� Sri 1,-,e "TfA <br /> • O • &x a-" Street Number Street Name <br /> CIT-YL" <br /> u Q D P STATE _ ZIP at _ <br /> PHONE#1 •`F'V E'T. APN# LAND UUSSE\APPLICATION# <br /> (nog) ggI - (old <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AK ^ `���0 <br /> V r` V1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE#o <br /> S S A CC 2z ►JC ' $I ►20 <br /> HOME Or MAILING All FAX# <br /> UO atAl\ S ACI nq4 I ( ) <br /> CITY t_Ai <br /> IrA,O-^ STATE ZIP sS2 n <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 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. IF SIGNATURE: DATE: <br /> LA Itp <br /> PROPERTY/BUSINESS OWNER OP RATOR MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS not the BILLING 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 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_ e PaMENT <br /> TYPE OF SERVICE REQUESTED: 1Tlla✓1 �/{'1PCi1G RECEIVE <br /> COMMENTS: MAY O 4 LIIJ <br /> �zr was CI lei <br /> ��nA�l-IGy'•�r SAN JOAOWNC NTY <br /> ENVIROMEN f kL <br /> HEALTH DEPART AENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1^q h EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5��23 Ply. 1(a01 <br /> Fee Amount: �.((� Amount Paid ? `7 �%, (� Payment Date <br /> Payment Type Invoice# Check# '?J Received By,-,7� _ <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />