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b bQ m57�(aC�a hoo-c om <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# gSERVICE REQUEST'#I —7 <br /> �rtt"oCeV of :2 JJZC)b . _ <br /> OWNER/OPERATOR <br /> lr {`r <br /> G t CHECK If BILLING ADDRESS <br /> G. <br /> FACILITY NAME <br /> NGYiaK QGZG2Gty' <br /> SfTE ADDRESS _ (� <br /> / I� RD � cn <br /> 6�lv � Street Number Direction ��m �n Street Name �(CC CI Zia Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (-0yl n I( <br /> 4-)e c L< L, c+� <br /> 6(IC+ Street Number Street Name <br /> CITY STATE ZIP <br /> G*0C V-�-AY1 " <br /> PHONE#1 APN# LAND USE APPLICATION It <br /> 0c0k)Ga3-31act <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> (0o9)Gd3 -oo-I Li <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> QV 1 vie L . ��)/�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME J PHONE# Ev. <br /> 31L G� <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY S T ZIP <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 /> 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: Q& n5/ DATE: 12- — I'LI — /6 <br /> OPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANKS not the BILLING PARTY proof of authorization t0 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)W, ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is proV r <br /> my representative. ��, <br /> TYPE OF SERVICE REQUESTED: `C <br /> COMMENTS: yF Fh Oq��/ Qj <br /> 'q�Tjy�O,y�ry�OU <br /> 4gpM�(N r <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: J EMPLOYEE#: DATE: <br /> Date Service Completed ( beady completed): SERVICE CODE: P I E: �a <br /> Fee Amount: �C 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 />