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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> j iype Of FusinesS Or Property FACILITY ID# QQSFRVICE REQUEST, <br /> (.,otO 111 N AW C,-A S � --iSI���10eli� <br /> OWNER,It OPERATOR <br /> —r 1 TV-A„1 E/ T ll� CHECK If BILLING ADDRESS <br /> FAC1ulYI ME IV _i f <br /> SITE ADDRESS a <br /> 17 aa 5-1 Street Number Direction J r1 Go IV`1q] St�c•et rvil ��"""G ���oil` <br /> HOLE Or ADDRESS (if Different from Site Address) <br /> V 15 I-k CX�K c4 r I i <br /> I Street Number I - Strect Name I <br /> CITY STATE ZIP <br /> 0-164- CIO qS-XEr— <br /> PUClrir 1 ExT APN# LAND USE APPLICATION# <br /> ( 9th 0 - 1 <br /> P11(-1.P "� Ex i. BOS DISTRICT LOCATIOI'J CODE <br /> -0i ) qCONTRACTOR / SERVICE REQUESTOR <br /> EOUESTOR <br /> R "`V""IF A-ri�,/ �� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE i! Ext. <br /> &t,L-F QO CT ( D! M� �t N I d - p <br /> HOME or MAILING ADDRESS FAX <br /> a 1 vis - Cl-P-Z-�I`-- C r _ --- - ( ) <br /> CITY ,� ej�--g'e� 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 EIl:!IROW,1E(1T..,L HEL.LTH DEPLRTLIENT hourly charges associated with this projector <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 S-r!Joroului <br /> COUNTY Ordinance Codes,Standards, S =TE and FED RAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: ��1 I <br /> PROPERTY/BUSINESS OWNER® RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ a NEe— <br /> lf APPLICANT is not the BILLING PARTY.proof of authorization to sign is required ri rrr <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 /> to the SAID JO GUIIJ COU1JT)' Ei \VIROI,IOENTAL HEALTH DER..RTr,IEIIT a5 SOOn as It is available and at the same time it is provided to me cr <br /> n-ly representative. ? <br /> TYPE OF SERVICE REQUESTED: Il/rD✓ RECEIVE <br /> COMI'JENtS: <br /> AUG 19 201 <br /> j SAN JOAQUIN COU TY <br /> OF OWm er S lip' ENVIRONMENTA <br /> HEALTH DEPARTM NT <br /> ACCEPTED BY: --TE <br /> #: DATE: R 1G�11q 01(A <br /> ASSIGNED TO: EMPLOYEE#: DATE: v 1� ' <br /> Date Service Completed (if already completed): SERVICE CODE: 0(-p <br /> (-0 <br /> Fee Amount- (�� '(� Amount Paid l S 2 _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EMD 43-02-025 SR FORM(Golden Rod) <br /> 07 17 08 <br />