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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �7AOuu Lion 2 y� � 122 <br /> OWNER/OPERATOR <br /> C0 rwD'1-A)0CA1-' oc Sly e,eYr ar) CHECK if BILLING ADDRESS <br /> FACILITY NAME g <br /> �jY�Q„Y 1/ ICA -1 "S <br /> De- �'` �t /T, <br /> SITE ADDRESS �y S3L2 ,/►� Y t--(\A I r\ e} ��)r'I g2-0S <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) &IC-55 C.I 1 <br /> Street Number rJ� Street Name <br /> CITY �`l 1' <br /> STATE, y� ZIP <br /> PHONE#1 `j EXT. APN# LAND USE APPLICATION# !/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> We r- CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' �jY'F C(Y10\0 is P QNE,# —1�l_ ���� EXT. <br /> HOME O MAILING ADDRESl FAX I#� <br /> -155 M L C <br /> Cli' j-v C STATE ,fin 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 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: �' i VLIJ Lti e�-- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proofx0fthorization 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 provided t0 me Or <br /> my representative. PA Vq <br /> TYPE OF SERVICE REQUESTED: -f—kZ CMAjj. 60 , eiV, <br /> COMMENTS: m\ O `^ n,rpl , /AA1 �+ <br /> SAN <br /> N EM'lRo�/N co , <br /> STH p pAR�"F 1Y <br /> �(,/ �'�/ /� T <br /> ACCEPTED BY: . 1 Y, 1l� � EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q NCC 'c EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: �� P/E: <br /> Fee Amount: 1 _ Amount Pa' / �v Payment Date <br /> Payment Type Invoice# I Check# 26 "Receive' By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />