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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ;Type of Business or ProperlyFACILITY ID# SERVICE REQUEST# <br /> FavO 6f) a17� SKM7NER I OPERATOR Srl lV0676 Ko ft,e Imw Viq9 o O r S" <br /> HECK If BILLING ADDRESS <br /> FACILITY NAME 106 /22� <br /> SITE ADDRESS <br /> 810 StreetNumber I pirec[ion Street Name 'CI ZI Cotle� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> — Stree[Number Slreel Name <br /> 11Z <br /> S <br /> CITY STATE ZIP <br /> o <br /> PHONE#1 EXT' APN IS LAND USE APPLICATION# <br /> - BOB- 'P-6 1 c) e) <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> 3 Af�) v <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR A^WC6P Ku _ r)D f CHECK If BILLING ADDRES <br /> BUSINESS NAME Ir ,q/yM1J PHONE# EnT. <br /> HOME or MAILING ADDRESS FAX# <br /> 3915 .rn c ( I <br /> CITY S,�OL r/}o k STATE /r L{ ZIP /7r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedl agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with INS 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, ST,09TE and FEDERAL law pQ R <br /> APPLICANT'S SIGNATURE: JU- a0h 10A DATE: v 6 ItF <br /> PROPERTY/BUSINESS OWNER PERATOR/M NAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> If APPLICANT iS n Ile 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 t0 me Or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: -)kt T <br /> COMMENTS: A�� 1 O <br /> I^.�lG✓]G� O� �s'1 P� sgv�40 6 ?01 <br /> ly4q�7�i 0 4f At <br /> ACCEPTED BY: EMPLOYEE#: DATE: �, ,/ Y <br /> ASSIGNED TO: EMPLOYEE <br /> EMPLOYEE#: DATE: UUU f� <br /> Date Service Completed) (iiff already completed): SERVICE CODE: PIE: da <br /> Fee Amount: c�)� — Amount Paid t��Z Payment Date <br /> Payment Type N <br /> ' Invoice# Check# Received By: &ij <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />