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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Mw1Cek llLe��av✓ ✓�� I-AOOdlsOdl S9,007�5049 <br /> OWNER I OPERATOR V _ <br /> (� ��t't �� 1 A'\t f--�' A.I � "� C 1►\ /' , CHECK If BILLING ADDRESS <br /> FACILITY NAME O[_p l 1DU r� r"f M R P-Yf-��� 1" I v f�1 <br /> SITE ADDRESS 2-) —C) 1 S Q S r <br /> T r� 1'_TSSC T rx�4-70�j C4�— . 46 <br /> Street Number Direction I 'S'tre`et'Name city ZI Code <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 /> ( ) <br /> PHONE#2 ExT' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> IA��rj ILL `� y( CHECK If BILLING ADDRESS <br /> BUSINESS NAME d r �rT �I \� 1^��Ylt%� �a IVVT \ PHONE# `r, ��r-r ExT. <br /> If I <br /> HOME Or MAILING ADDRESS 1 V FAX# <br /> CITY S7 cc keg 7 U STATE C ZIP G'i ,^2.0 <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 FEDET <br /> . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE1 ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof of authorization t0 sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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' formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is prOVIOr <br /> my representative. ��--777777 <br /> TYPE OF SERVICE REQUESTED: r PI(At (— tf` k I <br /> COMMENTS: 'J Cj M^\ �1 ,SgNJ ?y <br /> pUiv ?0, <br /> E9Cph�OFryy�TOfq WN <br /> ;I <br /> ACCEPTED BY: �� EMPLOYEE M DATE: lU- 7L.(O <br /> ASSIGNED TO: 1"\L'k EMPLOYEE M DATE: 10 .dy-17 <br /> Date Service Compl ed (if already completed): --TSI RACE �z3 PIE: I`01 <br /> Fee Amount: L4i�6 (?0 Amount Pard ' ,�,� Payment Date �.� 7 <br /> Payment Type -'�<� Invoice# jj Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />