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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ' 1 <br /> ►/�A \,/�/1 � �T1�/,1./1/' A/1� CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME A rol lei'•`1 <br /> SITE ADDRESS A hY)P� �:� � C"Ai <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) � -;A--` �O1Su�^ <br /> Street Number 1 Street Name <br /> CITY cv,-?,, V_✓_ + - ` STATE Cx IZIP <br /> PHONE#1 �V�L�ExT. APN# LAND USE APPLICATION# <br /> �1A �-�-10- 2 t-J 2 05c-)-3102-0 <br /> -71 <br /> PHONE#2 EXT. <br /> BOS DISTRICT LOCATION CODE <br /> ( ) Lc1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ✓I1 <br /> 10 In/\� �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME l I Y t/\ �\,`e,^= P JOE# , —),l _`�) EXT. <br /> �/'l.�� � 2 V�1 l r'l ov�'d� I +-� V <br /> HOME or MAILING ADDRESSi FAX# <br /> 7 <br /> 3 S 'V O <br /> CITY -5(1(' STATE ZIP C> <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ATE/and FEDERAL)aws_-- <br /> APPLICANT'S SIGNATURE: Ica;�t2 �/ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT its not the BILLING PARTY,proof of authorization to sign is required Ti[ie <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 rmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is prov Rr <br /> my representative. : <br /> TYPE OF SERVICE REQUESTED: 0 M%-AU74V <br /> COMMENTS: <br /> Om VkG)L- 0 L F; n p A11 �' <br /> �GTjy��(, �Ni <br /> , � FNr <br /> ACCEPTED BY: Y Y V . MVVv;VA 0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: C� O�AvAka, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E ' v <br /> Fee Amount: \C3 I Amount Pai Payment Date / <br /> Payment Type S� Invoice# ` Check# 87�73Sb Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />