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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> resi-wv rC'V,A �-28073762� <br /> OWNER/OPERATOR 'y ,,^l^`_ 1— <br /> � olorte-\C" kAr, IkeL -"VC hu <br /> CHECK If BILLINGADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction AC treet Name vl zip code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (alot) Ss33 0 �0�) <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> (sly) 01 -\bS 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1/ ,ry . <br /> A�f-`t e\C+� ,`D a't^I /U�e�— 1 , 1A L��'('�, CHECK It BILLING ADDRESS <br /> BUSINESS NAME D`�eY Cie t?-vv\2T- 2 15PHO1 J# Ol � 1 kos -1 <br /> ExT. <br /> HOME or MAILING ADDRESS FAX# `� <br /> kA rc- kjpw e\\ Pre ( ) <br /> CITY \��L CC'. STATE C ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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,Standara S,.STATE and FEDERAL laws. ��//���� "" ����''"� <br /> APPLICANT'S SIGNATURE:,�IA VJLY,cL,6 -1 1 o"r v,.l.[i DATE: (I (A 120 1 S <br /> PROPERTY/BUSINESS OWNERX OPERATOR I 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 /> to 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. t'� <br /> TYPE OF SERVICE REQUESTED: ©d r���1S�T w`�fU'1 1N3W18tld ONIANg 3H <br /> IAN3 <br /> COMMENTS: A1NnO3 NInOVOr NVS <br /> SIM 81 AON <br /> a3A(3Q3a <br /> 1.N3WAtfd <br /> ACCEPTED BY: EMPLOYEE M DAFE: I( om <br /> - ASSIGNED TO: SSCI �ItS�1N� EMPLOYEE#: DATE: III/ICy/15 <br /> Date Service Completed (if already completed): SERVICECODE: -�Co , I PIE: ICG02 <br /> Fee Amount: I�30 - Amount Paid Payment Date <br /> Payment Type ; - Invoice# Check# -' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �a <br />