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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR I A <br /> VII � CHECK If BILLING ADDRESS <br /> FACILITY NAME n I^ )—f-�—' O h <br /> SITE DDWO-5 I Ke ew►C'h s �,��f e (o 1� 5-.)— o <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRE S((If Diffe ennt from <br /> Site Add�r <br /> l/ � 1t, v '" M` Street Number Street Name <br /> CITY OC <br /> +01)` T TEt52 <br /> P <br /> P�D�, 6�113 8 8 Exr. APN# LAND USE APPLICATION# <br /> PHONE)Z I Q� /'� EXT. BIDS DISTRICT LOCATION CODE <br /> I /4 CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Kyl r, C &11')h tkA Irv, <br /> FPBUSINESS NAME f C L rA I' r 1 '1 PHONNE# ExT. <br /> HOME or MAILING A DRESS !1 VI ( FAX# IV J,}vS <br /> CITY J t /' O^7 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 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 Abal the wor e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST EDER Q r� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 environmental/site assessment information <br /> PAYMENT to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it IS P AYMENT <br /> my representative. <br /> F RECEIVE-11 <br /> TYPE OF SERVICE REQUESTED: Q <br /> COMMENTS: (\��r.,� o� 1 , Ae <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME14T <br /> ACCEPTED BY: �Y IJ EMPLOYEE#: DATE:(� l <br /> ASSIGNED TO: �l( EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: (�� PIE: ' -'-%2 <br /> Fee Amount: I�Z _. Amount Paid S ' _ Payment Date <br /> Payment Type Invoice# Claetk# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> CP-054 I <br /> a^I <br />