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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> p II�M 's CIF __Fl � 3 y�1 (� 5(L007 5r <br /> OWNER/OPERATOR <br /> CHECK IfBILLINGADDRESS <br /> FACILITY NAME 1. <br /> SITE ADDRESS Q r <br /> rV �rnl1� C—� <br /> 2 �4/c1+ O" Sloc.'r�v-. �iYZoG <br /> Street Number DlrecHon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S/ S- (aw-0.1- <br /> Street Number Street Name <br /> CITY S� STATE Zip ck aa� CIS20� <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> (M) ( 62- Mo Ito[ old <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4 <br /> LF 1c CHECK if BILLING AD ESS <br /> BUSINESS NAME /•^ <br /> v Q Dreo K LLC, PHONE# 07-LJS'Q t. Exr. <br /> wor— <br /> HOME Or MAILING ADDRESS FAX# <br /> y�4S CpYUvterdo 4ae ( ) <br /> CIN STATE CA ZIP 4rzri <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, Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: L//( /C11) <br /> PROPERTY/BUSINESS OWNER Yw OPERATOR/M GER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof Of authorization t0 Sign IS required Tifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assessm mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS pr,Qyj r <br /> my representative. _K�Gc <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> r , <br /> �-t LQ/1r� 2 C.f Ot�T�Pf N �RONNCOUN <br /> UEPgR M NT <br /> ACCEPTED EMPLOYEE#: DATE: '1_ /o <br /> ASSIGNED TO:O: ec EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: O <br /> Fee Amount: IAmount Pai / ob Payment Date <br /> Payment Type (7 i,�J Invoice# Check# Recte ved By: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />