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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ') u�--h it q �U G'17J'�`-� <br /> OWNER/OPERATO <br /> FACILITY NAM ! l�Cl.� >>> CHECK if BILLING ADDRESS <br /> E air <br /> e ( / <br /> SITE ADDRESS //f�// C1 1 ��,fj��.i�}'7//,{r <br /> Cl tr t�u.ber Direction ' "G" ( etreet Name ` Ti Cod7e C` <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> > J-- <br /> 166 50 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR <br /> // SAERVICE REQUESTOR <br /> REQUESTOR ��dL (`! <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME��/ Com, J 7 0 ��` �C PHONE# / 1 '7t ExT. <br /> HOME Or MAILING ADDRESS / C�� (AX# ) <br /> r e4v <br /> CITY Z04 <br /> �` STATE ZIP ���72 <br /> BILLING ACKNOWL(EDGEMENT: 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 appiica' and t the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT and FEDERA <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP R/MANAGER OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the B UNG 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It is pr Cd to <br /> Vme or <br /> my representative. �yt � w, <br /> TYPE OF SERVICE REQUESTED: V 1`-c- wn sv 1� / l cn <br /> COMMENTS: R <br /> p C 2 0 � %'/0 �2 ?019 <br /> C—F-S IT) I c I U 3 �-�– y o9 q co <br /> =r RTM�HT <br /> ACCEPTED BY: n h EMPLOYEE#: DATE: <br /> ASSIGNED TO: VVV��1 I� EMPLOYEE#: DATE: s� j'2Y I�jjl <br /> Date Service Completed (if already completed): L�f2/ j� SERVICE CODE: �(P ) 1 PIE: IgU12 <br /> Fee Amount: /5-:2..(7D Amount Pai S�z,vz:) Payment Date <br /> Payment Type `-<-"�— Invoice# Check# 3 �) 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />