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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SuRwAy F55AS2i 6b 7`65��► <br /> OWNER/OPERATOR <br /> � CHECK if BILLING ADDRESS <br /> [1)1 AA <br /> W <br /> FACILITY NAME Q Lk ���� <br /> SITE ADDRESS `J Lf 2-0� _l -1-z�r t��py - <br /> 2V' I Street Number Direction Nr�GLcc Street Name 11 CI ZI Cotle <br /> HOME r-Or MAILING ADDRESS (If Different from Site Address) (� <br /> 3 20Amb 1v I,) L d Street Number C A Street Name 1 5 ?Z <br /> CITY STATE ZIP <br /> Racy <br /> PHONE#'I �1(D 4'51-1 ExT' APN# LAND USE APPLICATION# <br /> (S.1 ) LIS7 c99'z I09q 1 2 qoa <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (Sig) Q7(" (11,17 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C J L,11 MRt/ CHECK if BILLING ADDRESS <br /> JPHONE# EnT. <br /> BUSINESS NAME VJ/',r-.L 'l $1 199-7 <br /> HOME Or MAILING ADDRESS FAX# <br /> 71 <br /> 2-1;m lb11TZ)NIJ .( o Jjo ( ) <br /> CITY T"Tcy STATE ^'A ZIP n�-3 7-1 <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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12- -lo -17 <br /> PROPERTY I BUSINESS OWNERPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization f0 sign is required Tire <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 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. �/ <br /> TYPE OF SERVICE REQUESTED: ' <br /> COMMENTS: <br /> �N UOA <br /> QIJ <br /> hEglT DEPgE 17,G <br /> SAFr <br /> ACCEPTED BY: EMPLOYEE#: DATE: Hap- I' <br /> ASSIGNED TO: EMPLOYEE#: DATE: l//� -,'z G.I 17 <br /> Date Service Completed (if already completed): SERVICE CODE: 0 t PIE: da <br /> Fee Amount: 1-J d-3 Amount Paid 5 2 D T Payment Date 12-12-0 r <br /> Payment Type ✓ Invoice# Check# Gl Grs Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />