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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID' SERVICE REQUEST# <br /> t--bckeru� 4wzlNfrs <br /> OWNER/OPERATOR <br /> . 1� a/A,.J CHECK if BILLING ADDRESS <br /> FACILITY NAME Vim,., O r, IL <br /> SITE ADDRESS (�Km � �.• 1 7 �/ ( �j cj S-'Z3 <br /> 3 8d <br /> Street Number Direction � I I Vv Stree[Name city Zip C¢tla <br /> H Mr nr Mn INr,ADDRESf Di ent from Site Address) <br /> 1 <br /> Street Number Street Name <br /> CITY ) D STATE C /fI ZIP 9 SZ Z 7 <br /> PHONE#1 APN# LAND USE APPLICATION# / <br /> 00- 9 - 5 - 0J 32 <br /> PHONE42 T BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 12 <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME /7 �O T PHONE <br /> HOME Or MAILING ADDRESS^0 lJox f- ^/S'r FAX# <br /> CITY / QC �D STATE C14 ZIP 7 <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, n RAyaws. 2 <br /> APPLICANT'S SIGNATURE: // DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is 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 information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time ItIs '"r <br /> rovided to me Or <br /> my representative. �9n A <br /> TYPE OF SERVICE REQUESTED: + �v/ �b� �VVPrC: <br /> COMMENTS: l� <br /> c12 SAN jo l Zl�l rj <br /> ENV/ QUIN CO <br /> HEA[THOF,P R MENS <br /> ACCEPTED BY. EMPLOYEE#: DATE: o2 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P/E: <br /> Fee Amount: 5 d— Amount Paid - 15� OD 1 <br /> Payment Date 2-1131,g- <br /> Payment <br /> r13II Payment Type Invoice# Check# )O p 3 Received By: (,�J <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 C <br />