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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> -Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'L L F� oD6 qJ - 5 slob-7ggg---� <br /> OWNER I OPERATOR <br /> N E -S LLC wY CHECK If BILLING ADDRPAP 7P <br /> ` <br /> QLI Y AM <br /> SITE ADDRESS d� /� �9 <br /> w Mcl eWA( "6 Direction Street Name <br /> HOME Or f-AILI//"w(--.ADDRESS Of Different from Site Address) <br /> Street Numbera�aVksl✓ $tet tl�nc_ <br /> l CI'Y STATE zip <br /> 6A 1 <br /> PHONE#1 EXT. APN A LAND USE APPLICATION# <br /> bCdce 49I� 6���c <br /> PHONE#2 Ext. SOS DISTRICT =PATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> AL <br /> AL. 'J �/����y� CHECK If BILLING ADDRESS <br /> Bu INESs NAME I t� PHONE# EXT. <br /> ► qMC I-)0 90 JM 1-87?75 <br /> HOME Or MAILING ADDRESS FAX# <br /> ) <br /> CITY OCKTO AJ $a'{f, zip -?5-Z6 <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 T E and FEDE L laws. <br /> APPLICANT'S SIGNAT'IIRE: DATE: 617 12o 16 <br /> PROPERTY I BUSINESS OWNER© OPERATOR 1 MANAGE OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 environmentallsiite 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, <br /> TYPE OF SERVICE REQUESTED: � ��� <br /> COMMENTS: E <br /> JUN U 7 201S <br /> 'AN J0.4QUJN COUN <br /> rl <br /> ENVIROMENTAL <br /> HEALTH OEPARTlt4E <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: t—, '7_ ! <br /> ^ r <br /> I ASSIGNED TO: f\� ts5 EMPLOYEE#: DATE: t// <br /> Date Sen ice Completed (if already completed): SERVICE CODE: 2 t1P1/E: /Ipo) <br /> Amount Paid -Payment Date <br /> Fee Amount: 3�p • -- <br /> Payment Type C•tk 4- tPA4 Invoice# Check#8rnP4)4,4-qS Received By: 46% <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> w <br />