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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> X21 uogoo(5-0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME E C0\eS -V k <br /> SITE ADDRESS 3 Zo� w ��-�!1)CA M�I Y-1 1�1+ 17 r . �v C �,�► Gl 521�1 <br /> Street Number Direction Street Name \2\ Ci Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) f ^ <br /> Street Number 1� Street Name <br /> CITY C�=`! �\ STATE O ,� ZIP 0 ;— <br /> PHONE 1 J V li �-�� Exr. APN# LAND USE APPLICATION# "l <br /> LA ul <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `v CHECK if BILLING ADDRES <br /> BUSINESS NAMEa! I ���c , /�a ( � Py Jett N� �' <br /> HOME or MAILING ADDRESS FAX <br /> ## l lY <br /> 1 ( ) <br /> CITY ! "-�� STATE ('/� ZIP �� 7 Z <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 /> 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, Standar , TA nd FEDERAL <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ j <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 locat d at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assess ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It isJ� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: i ��/�� �1/�, JAN <br /> COMMENTS: (� ► _ 11, t� �(\^/t ,nr �fj ^ •, - w'111/jOq �9 <br /> Fly QUI <br /> HFq�H pXPMCo LNrY <br /> FNT <br /> ACCEPTED BY: EMPLOYEE EMPLOYEE#: DATE: <br /> ASSIGNED TO: Y� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (., PIE: <br /> Fee Amount: 1 C52 C)C) Amount P ,52 ,D Payment Date Y <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 51 QQ� Cj �(} ��7 Gi 12D SR FORM(Golden Rod) <br /> 07/17/08 IC"' <br /> X120 53� 1-14 <br />