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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> MDRELlA M f'K ::] <br /> OWNER f OPERATOR <br /> 1!Y G CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 <br /> SITE ADDRE1— 17 }.{ z LT'a Q/il�� fZv <br /> I 102— Street Number Direction /, Street Name lll/C//I�J (721 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> /U7•. Street Number r l Street am <br /> TATE ZIP?��j.�� <br /> PHONE'1 2�U / / EXT* APN# q �� LAND USE APPLICATION# G L <br /> PHONE#2 J EXT. 1 -L) BOS DISTRICT LOCATION CODE <br /> o CU 1 <br /> ONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME V �--� PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE 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 /> 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 /> CouNry Ordinance Codes, StandardZSand FEDER laws.APPLICANTS SIGNATURE: n DATE: e5 — <br /> PROPERTY/BUSINESS OWNER❑ PERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization t0 sign is required Thle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locatethe above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessor at ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is Qf� <br /> my representative. C <br /> TYPE OF SERVICE REQUESTED: 4 4 fU <br /> COMMENTS: 'IO O10 <br /> H F 'O A(C <br /> FACTyO�P Ftp Nh <br /> 4 T"7A4 <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: M JAEMPLOYEE#: DATE: 13 1& <br /> Date Service Completed If already completed): SERViCECODE: O PIE: I CCJJ <br /> Fee Amount: 1 ao0 Amount Pai /sa D D I <br /> Payment Date '�3 <br /> Payment Type LI I Invoice# Check# ece' ed By: <br /> EHD 48-02-025 J-7l ,fir 1 SR FORM(Golden Rod) <br /> 07/17/08 /(/ I� I <br />