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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fkw3a--;:Z� I 52 6679'/3 <br /> OWNER/OPERATOR <br /> -L CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> LL <br /> SITE ADDRESS $$ �A LC qq�-14 <br /> Street Number I Direction S[reet Name city ZI Code <br /> HOME Or MAILING ADDRESS (if Different from Site AddrftfSIL0 CA ess) <br /> L—(i-e+'\ wf Street Name <br /> CITYSTATE ZIP <br /> _ <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (4Q& �3K-CAA-r X3 2 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( s) G -8g 3(- Ob 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR — <br /> ,:4—`O freyyV CHECK If BILLING ADDRESS <br /> BUSINESS NAME ��/� PHONE# Ext. <br /> 5� fX�(J� JrWIIS L.ZC I aoCt go__.4_ �Il <br /> HOME Or MAILING ADDRESS FAx# <br /> S43 S 1 ( ) <br /> CITY STATE c. <br /> BILLING ACKNOWLE GEMENT: 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 /> also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard A and FEDERAL laws. <br /> APPLICANT'$SIGNATUR . DATE: 51a l II <br /> PROPERTY/BUSINESS OWNER El 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 ass sment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It ed to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: >tAo o AZ A7V <br /> COMMENTS: 1' <br /> Ch(A 6 F C"i bit?el, IN <br /> co 418 <br /> 114Z4NPg' Y <br /> HEFT <br /> ACCEPTED BY: qn� EMPLOYEE DATE: 5-11- 116 <br /> _ fly) <br /> ASSIGNED TO: BCW EMPLOYEE#: DATE: 5-,a ) �(J7r <br /> Date Service Completed (if already completed): SERVICE CODE: �7 f PIE: Q� <br /> Fee Amount: �CD;L- AmountPai ����/ Payment Date Lj <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />