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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �TA� ➢/Z41� 000 Zuo�l�l �(zoo743SS <br /> OWNER/OPERATO <br /> � 1A so'' I /� CHECK If BILLING A0DRE5S❑ <br /> FACILITYNAMENAME l/ tA �t/JYrzl [y�T'C7— I <br /> SITE ADDRESS a�C'03 �� '7 X79 °// L(rU\ <br /> Stree[Number Direction -' � Street Name ciN <br /> HUM Or MAILIN A--//D��D77REES�SS (if <br /> Different from Site Address) L �� .. <br /> 0 4 LYl` /�i Street Number "t-L1// v Street Name -_ <br /> CITY 7 n� A ZIP Y <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (OS Z4e . CO-S 3- <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR --r�(�.,5 w / ISI <br /> �f•Ac�J/V JU CHECK if BILLING ADDRESS LI <br /> BUSINESS NAMEPHONE# ECT. <br /> � 4�,Q/�r�20 s- •005 <br /> HOME Or MAILING ADDRESS 2S/� � /�T72�� ��1/� FAX# <br /> off] (t� ��Cly(1 �J V ( ) <br /> CITY �.n C� //_ STATE ZIP <br /> BILLING ACKNOWLE GEMENT: 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 a pl' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE nd FEDERALlaWrp. <br /> APPLICAN ' RE: DATE: <br /> PROPER /BUSINESS OWN ERATOR/MANAGE .q OTHER AUTHORIZED AGENT ❑ _ <br /> ANT is no ILLING PARTY pr f 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 If ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided ta ➢r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: T65>'A CG;Vt.�iu�- <br /> COMMENTS: /7ti// ALV 4y-W / �'��� Ary O <br /> f icC f "r 0""6 oov ry <br /> `^tT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: e—'t c' 'v l,S t•y0 EMPLOYEE#: DATE: 2T7� <br /> Date Service Completed (if already completed): SERVICE CODE: <;,cG0 P//E: <br /> Fee Amount: (_q I ao-pi7 I Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 1-3 in S <br />